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1.  Piloting the role of a pharmacist in a community palliative care multidisciplinary team: an Australian experience 
BMC Palliative Care  2011;10:16.
Background
While the home is the most common setting for the provision of palliative care in Australia, a common problem encountered here is the inability of patient/carers to manage medications, which can lead to misadventure and hospitalisation. This can be averted through detection and resolution of drug related problems (DRPs) by a pharmacist; however, they are rarely included as members of the palliative care team. The aim of this study was to pilot a model of care that supports the role of a pharmacist in a community palliative care team. A component of the study was to develop a cost-effective model for continuing the inclusion of a pharmacist within a community palliative care service.
Methods
The study was undertaken (February March 2009-June 2010) in three phases. Development (Phase 1) involved a literature review; scoping the pharmacist's role; creating tools for recording DRPs and interventions, a communication and education strategy, a care pathway and evidence based patient information. These were then implemented in Phase 2. Evaluation (Phase 3) of the impact of the pharmacist's role from the perspectives of team members was undertaken using an online survey and focus group. Impact on clinical outcomes was determined by the number of patients screened to assess their risk of medication misadventure, as well as the number of medication reviews and interventions performed to resolve DRPs.
Results
The pharmacist screened most patients (88.4%, 373/422) referred to the palliative care service to assess their risk of medication misadventure, and undertook 52 home visits. Medication reviews were commonly conducted at the majority of home visits (88%, 46/52), and a variety of DRPs (113) were detected at this point, the most common being "patient requests drug information" (25%, 28/113) and "condition not adequately treated" (22%, 25/113). The pharmacist made 120 recommendations in relation to her interventions.
Fifty percent of online survey respondents (10/20) had interacted 10 or more times with the pharmacist for advice. All felt that the pharmacist's role was helpful, improving their knowledge of the different medications used in palliative care. The six team members who participated in the focus group indicated that there were several benefits of the pharmacist's contributions towards medication screening and review.
Conclusions
The inclusion of a pharmacist in a community palliative care team lead to an increase in the medication-related knowledge and skills of its members, improved patients' medication management, and minimised related errors. The model of care created can potentially be duplicated by other palliative care services, although its cost-effectiveness was unable to be accurately tested within the study.
doi:10.1186/1472-684X-10-16
PMCID: PMC3215169  PMID: 22035160
2.  New Roles for Pharmacists in Community Mental Health Care: A Narrative Review 
Medicines are a major treatment modality for many mental illnesses, and with the growing burden of mental disorders worldwide pharmacists are ideally positioned to play a greater role in supporting people with a mental illness. This narrative review aims to describe the evidence for pharmacist-delivered services in mental health care and address the barriers and facilitators to increasing the uptake of pharmacist services as part of the broader mental health care team. This narrative review is divided into three main sections: (1) the role of the pharmacist in mental health care in multidisciplinary teams and in supporting early detection of mental illness; (2) the pharmacists’ role in supporting quality use of medicines in medication review, strategies to improve medication adherence and antipsychotic polypharmacy, and shared decision making; and (3) barriers and facilitators to the implementation of mental health pharmacy services with a focus on organizational culture and mental health stigma. In the first section, the review presents new roles for pharmacists within multidisciplinary teams, such as in case conferencing or collaborative drug therapy management; and new roles that would benefit from increased pharmacist involvement, such as the early detection of mental health conditions, development of care plans and follow up of people with mental health problems. The second section describes the impact of medication review services and other pharmacist-led interventions designed to reduce inappropriate use of psychotropic medicines and improve medication adherence. Other new potential roles discussed include the management of antipsychotic polypharmacy and involvement in patient-centered care. Finally, barriers related to pharmacists’ attitudes, stigma and skills in the care of patients with mental health problems and barriers affecting pharmacist-physician collaboration are described, along with strategies to reduce mental health stigma.
doi:10.3390/ijerph111010967
PMCID: PMC4211017  PMID: 25337943
pharmacist; mental health care; quality use of medicines; community pharmacy; service implementation
3.  Randomised evaluation of the Italian medicines use review provided by community pharmacists using asthma as a model (RE I-MUR) 
Background
The Italian Ministry of Health decided to introduce community professional services in 2010. This trial provides an opportunity to evaluate the outcomes of a new professional pharmacy service: Italian Medicines Use Review (I-MUR) aimed at reducing the severity of asthma and its associated costs.
Methods/Design
This is a cluster randomised controlled trial of the I-MUR service. Data will be collected over time before, during and after pharmacists’ intervention. Fifteen Italian regions will be involved and it is aimed to recruit 360 community pharmacists and 1800 patients. Each pharmacist will receive training in medicines use review, recruit five patients, administer the Asthma Control Test and provide the I-MUR service. Pharmacists will be allocated to different groups, one group will be trained in and provide the I-MUR service immediately after completion of the baseline ACT score, the other group will receive training in the I-MUR and provide this service three months later. Group allocation will be random, after stratification by region of Italy. The I-MUR service will involve gathering data following each patient consultation including demographic details, patients regular medications, including those used for asthma, their attitude towards their medications and self-reported adherence to treatments. In addition, pharmacists will identify and record pharmaceutical care issues and any advice given to patients during the I-MUR, or recommendations given to doctors. Pharmacists will upload trial data onto a web platform for analysis. The primary outcome measure is the severity of asthma before, during and after the I-MUR assessed using the Asthma Control Test score. Secondary measures: number of all active ingredients used by patients during and after the I-MUR, number of pharmaceutical care issues identified during the I-MUR, patients’ self-reported adherence to asthma medication during and after the I-MUR, healthcare costs based on the severity of asthma, before, during and after the I-MUR service provision.
Discussion
This study has been developed because of the need for a new way of working for pharmacists and pharmacies; it is the first trial of any community pharmacy-based pharmaceutical care intervention in Italy. The results will inform future policy and practice in Italian community pharmacy.
Trial registration number
ISRCTN72438848.
doi:10.1186/s12913-015-0791-6
PMCID: PMC4422306  PMID: 25896873
Asthma; Medicines use review; Cluster randomised controlled trial (RCT); Community pharmacy
4.  Design of the POINT study: Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in a primary care Team (POINT) 
BMC Family Practice  2015;16:76.
Background
In the Netherlands, 5.6 % of acute hospital admissions are medication-related. Almost half of these admissions are potentially preventable. Reviewing medication in patients at risk in primary care might prevent these hospital admissions. At present, implementation of medication reviews in primary care is suboptimal: pharmacists lack access to patient information, pharmacists are short of clinical knowledge and skills, and working processes of pharmacists (focus on dispensing) and general practitioners (focus on clinical practice) match poorly. Integration of the pharmacist in the primary health care team might improve pharmaceutical care outcomes.
The aim of this study is to evaluate the effect of integration of a non-dispensing pharmacist in general practice on the safety of pharmacotherapy in the Netherlands.
Methods
The POINT study is a non-randomised controlled intervention study with pre-post comparison in an integrated primary care setting. We compare three different models of pharmaceutical care provision in primary care: 1) a non-dispensing pharmacist as an integral member of a primary care team, 2) a pharmacist in a community pharmacy with a predefined training in performing medication reviews and 3) a pharmacist in a community pharmacy (care as usual). In all models, GPs remain accountable for individual medication prescription. In the first model, ten non-dispensing clinical pharmacists are posted in ten primary care practices (including 5 – 10 000 patients each) for a period of 15 months. These non-dispensing pharmacists perform patient consultations, including medication reviews, and share responsibility for the pharmaceutical care provided in the practice. The two other groups consist of ten primary care practices with collaborating pharmacists. The main outcome measurement is the number of medication-related hospital admissions during follow-up. Secondary outcome measurements are potential medication errors, drug burden index and costs. Parallel to this study, a qualitative study is conducted to evaluate the feasibility of introducing a NDP in general practice.
Discussion
As the POINT study is a large-scale intervention study, it should provide evidence as to whether integration of a non-dispensing clinical pharmacist in primary care will result in safer pharmacotherapy. The qualitative study also generates knowledge on the optimal implementation of this model in primary care. Results are expected in 2016.
Trial registration number
NTR4389, The Netherlands National Trial Register, 07-01-2014.
doi:10.1186/s12875-015-0296-8
PMCID: PMC4489035  PMID: 26135582
Pharmacotherapy; Polypharmacy; Non-dispensing clinical pharmacist; General practice; Primary care; Hospitalisation
5.  Pharmacists’ communication with Spanish-speaking patients: a review of the literature to establish an agenda for future research 
Background
Spanish-speaking people represent more than 12% of the total population in the United States and are poised to become the largest minority group in the U.S. by 2015. Although researchers have studied pharmacist-patient communication for approximately 30 years, little emphasis has been placed on the interactions between pharmacists and Spanish-speaking patients.
Objective
The objectives of this review are 1) to describe empirical studies on Spanish-speaking patient/pharmacist communication examined relative to patient factors, pharmacist factors, and environmental factors that may influence Spanish-speaking patient/pharmacist communication and 2) to integrate medical and nursing literature to generate a research agenda for future study in this area.
Methods
We compiled articles from a systematic review of (1) CINAHL, International Pharmacy Abstracts, Pub Med, and Web of Knowledge databases using “Hispanic limited English proficiency”, “Latino limited English proficiency”, “language-assistance services”, “Spanish-speaking patients”, “Latino patients”, “Spanish-speaking health literacy”, “pharmacy health literacy”, “patient-provider communication”, “pharmacy language barriers”, (2) bibliographies of selected articles.
Results
This search generated 1,174 articles, 7 of which met the inclusion criteria. We categorized the results into four topic areas: “Spanish-speaking patient literacy,” “pharmacists knowledge of/proficiency in the Spanish language,” “pharmacy resources to overcome language barriers,” and “pharmacists’ attitudes towards communicating with Spanish-speaking patients.”
Conclusions
These studies provide a macroscopic look at the linguistic services offered in pharmacies, gaps in services, and their subsequent impact on pharmacists and patients. Future research should investigate Spanish-speaking patients’ literacy issues, pharmacy staff language skills, factors that influence pharmacists’ counseling, and language assistance programs for pharmacists and patients. Furthermore, these studies need to be conducted in large Hispanic/Latino populated areas where positive service models are likely to be present. Addressing these issues will provide pharmacists and pharmacies with information to overcome language barriers and provide Spanish-speaking patients with quality care.
doi:10.1016/j.sapharm.2008.05.005
PMCID: PMC2875142  PMID: 19524859
Hispanic limited English proficiency; language-assistance services; Spanish-speaking patients; patient-provider communication; pharmacy language barriers
6.  Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice 
BMJ : British Medical Journal  2001;323(7325):1340.
Objective
To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice.
Design
Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review.
Setting
Four general practices.
Participants
1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community.
Intervention
Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment.
Main outcome measures
Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services.
Results
590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference £4.72 per 28 days, −£7.04 to −£2.41); equivalent to £61 per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference −0.2, −0.4 to −0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate.
Conclusions
A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.
What is already known on this topicReview of patients on long term drug treatment is important but is done inadequatelyEvidence from the United States shows that pharmacists can improve patient care by reviewing drug treatmentWhat this study addsConsultations with a clinical pharmacist are an effective method of reviewing the drug treatment of older patientsReview by a pharmacist results in more drug changes and lower prescribing costs than normal care plus a much higher review rateUse of healthcare services by patients is not increased
PMCID: PMC60673  PMID: 11739221
7.  Public health in community pharmacy: A systematic review of pharmacist and consumer views 
BMC Public Health  2011;11:582.
Background
The increasing involvement of pharmacists in public health will require changes in the behaviour of both pharmacists and the general public. A great deal of research has shown that attitudes and beliefs are important determinants of behaviour. This review aims to examine the beliefs and attitudes of pharmacists and consumers towards pharmaceutical public health in order to inform how best to support and improve this service.
Methods
Five electronic databases were searched for articles published in English between 2001 and 2010. Titles and abstracts were screened by one researcher according to the inclusion criteria. Papers were included if they assessed pharmacy staff or consumer attitudes towards pharmaceutical public health. Full papers identified for inclusion were assessed by a second researcher and data were extracted by one researcher.
Results
From the 5628 papers identified, 63 studies in 67 papers were included. Pharmacy staff: Most pharmacists viewed public health services as important and part of their role but secondary to medicine related roles. Pharmacists' confidence in providing public health services was on the whole average to low. Time was consistently identified as a barrier to providing public health services. Lack of an adequate counselling space, lack of demand and expectation of a negative reaction from customers were also reported by some pharmacists as barriers. A need for further training was identified in relation to a number of public health services. Consumers: Most pharmacy users had never been offered public health services by their pharmacist and did not expect to be offered. Consumers viewed pharmacists as appropriate providers of public health advice but had mixed views on the pharmacists' ability to do this. Satisfaction was found to be high in those that had experienced pharmaceutical public health
Conclusions
There has been little change in customer and pharmacist attitudes since reviews conducted nearly 10 years previously. In order to improve the public health services provided in community pharmacy, training must aim to increase pharmacists' confidence in providing these services. Confident, well trained pharmacists should be able to offer public health service more proactively which is likely to have a positive impact on customer attitudes and health.
doi:10.1186/1471-2458-11-582
PMCID: PMC3146877  PMID: 21777456
8.  Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study) 
BMJ Open  2012;2(3):e000918.
Objectives
To test the impact of a hospital pharmacist-prepared interim residential care medication administration chart (IRCMAC) on medication administration errors and use of locum medical services after discharge from hospital to residential care.
Design
Prospective pre-intervention and post-intervention study.
Setting
One major acute care hospital and one subacute aged-care hospital; 128 residential care facilities (RCF) in Victoria, Australia.
Participants
428 patients (median age 84 years, IQR 79–88) discharged to a RCF from an inpatient ward over two 12-week periods.
Intervention
Seven-day IRCMAC auto-populated with patient and medication data from the hospitals' pharmacy dispensing software, completed and signed by a hospital pharmacist and sent with the patient to the RCF.
Primary and secondary outcome measures
Primary end points were the proportion of patients with one or more missed or significantly delayed (>50% of prescribed dose interval) medication doses, and the proportion of patients whose RCF medication chart was written by a locum doctor, in the 24 h after discharge. Secondary end points included RCF staff and general practitioners' opinions about the IRCMAC.
Results
The number of patients who experienced one or more missed or delayed doses fell from 37/202 (18.3%) to 6/226 (2.7%) (difference in percentages 15.6%, 95% CI 9.5% to 21.9%, p<0.001). The number of patients whose RCF medication chart was written by a locum doctor fell from 66/202 (32.7%) to 25/226 (11.1%) (difference in percentages 21.6%, 95% CI 13.5% to 29.7%, p<0.001). For 189/226 (83.6%) discharges, RCF staff reported that the IRCMAC improved continuity of care; 31/35 (88.6%) general practitioners said that the IRCMAC reduced the urgency for them to attend the RCF and 35/35 (100%) said that IRCMACs should be provided for all patients discharged to a RCF.
Conclusions
A hospital pharmacist-prepared IRCMAC significantly reduced medication errors and use of locum medical services after discharge from hospital to residential care.
Article summary
Article focus
Medication administration errors are common when patients are discharged from hospital to a residential care facility (RCF). In Australia, a contributing factor is the need for the patient's primary care doctor to attend the RCF at short notice to write a medication administration chart; when the doctor cannot attend, doses may be missed or delayed and a locum doctor may be called to write a medication chart.
The objective of this study was to test the impact of a hospital pharmacist-prepared residential care medication administration chart (IRCMAC) on medication administration errors and use of locum medical services after discharge from hospital.
Key messages
Provision of a hospital pharmacist-prepared IRCMAC resulted in significant reductions in missed or delayed medication doses and use of locum medical services after discharge from hospital.
RCF staff reported that the IRCMAC improved continuity of care, and primary care doctors reported that it reduced pressure on them to attend RCFs at short notice.
Strengths and limitations of this study
This is the first study to evaluate the impact of a hospital-provided IRCMAC on medication errors or use of locum medical services. Strengths were that the two study groups were well matched in terms of demographics, ward type, number of medications and number of RCFs.
The main limitations were the use of a pre-intervention and post-intervention study design and data collection via RCF staff telephone interview. However, quantitative data on medication errors and use of locum services were validated by strongly positive feedback from RCF staff and doctors and widespread uptake and ongoing use of the IRCMAC.
doi:10.1136/bmjopen-2012-000918
PMCID: PMC3367148  PMID: 22637373
9.  Counselling practices in community pharmacies in Riyadh, Saudi Arabia: a cross-sectional study 
Background
Community pharmacists play a crucial role in optimising medication use and improving patient outcomes, whilst preventing medication misuse and reducing costs. Evidence suggests that pharmacists counselling improves clinical outcomes, quality of life, drug and disease knowledge and reduces health service utilisation. This study aims to investigate the counselling practices of community pharmacists in Riyadh, the capital of Saudi Arabia.
Methods
The study consisted of two parts: simulated patients (SPs) visits to observe actual counselling practices, and a cross-sectional survey of community pharmacists to assess their reported counselling practices. In the SPs method, there were four scenarios involving four medications. Scenarios 1 and 2 concerned drug–drug interactions, scenario 3 concerned the proper time of administration, and scenario 4 concerned side effects. The simulated visits were conducted between April and May 2012. A four-sections questionnaire was distributed in the same period.
Results
We conducted 161 simulated visits. Out of the 161 visits a medicine was dispensed in 150 visits. When SPs requested medications, pharmacists asked questions during 15 visits (10.0 %), provided information during 7 visits (4.6 %), and both asked questions and provided information, i.e. provided counselling, during 4 visits (2.6 %). When the SPs started to be inquisitive and demanded information, pharmacists asked SPs questions during 71 visits (47.3 %), provided information during 150 visits (100 %), and both asked questions and provided information, i.e. provided counselling, during 65 visits (43.3 %). Information regarding dose was the most common type of information provided in 146 visits (97.3 %). After the SPs started to be inquisitive and probed for information, only 10 % were counselled on precautions. In the cross-sectional survey, four hundred pharmacists were approached and 350 agreed to participate in the questionnaire (87 % response rate). Of the respondents, 223 (63.7 %) reported that they usually or always tell the patient about the purpose of medicines or the diagnosis, 302 (86.2 %) reported that they usually or always give patient information on how to use or apply the medicine; 299 (85.3 %) said they were satisfied with their counselling practices.
Conclusions
The present study highlights the current deficiencies in appropriate dispensing practices and medication counselling at community pharmacies in Saudi Arabia. Policy makers, stakeholders, and researchers should collaborate to design interventions to improve the current dispensing practices at community pharmacies across the country.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-1220-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-1220-6
PMCID: PMC4678714  PMID: 26669857
Community pharmacy; Patient simulation; Counselling; Lay perspectives; Patient safety
10.  An exploration of the role of pharmacists within general practice clinics: the protocol for the pharmacists in practice study (PIPS) 
Background
Medication-related problems are a serious concern in Australian primary care. Pharmacist interventions have been shown to be effective in identifying and resolving these problems. Collaborative general practitioner-pharmacist services currently available in Australia are limited and underused. Limitations include geographical isolation of pharmacists and lack of communication and access to patient information. Co-location of pharmacists within the general practice clinics is a possible solution. There have been no studies in the Australian setting exploring the role of pharmacists within general practice clinics.
The aim of this study is to develop and test a multifaceted practice pharmacist role in primary care practices to improve the quality use of medicines by patients and clinic staff.
Methods/design
This is a multi-centre, prospective intervention study with a pre-post design and a qualitative component. A practice pharmacist will be located in each of two clinics and provide short and long patient consultations, drug information services and quality assurance activities. Patients receiving long consultation with a pharmacist will be followed up at 3 and 6 months. Based on sample size calculations, at least 50 patients will be recruited for long patient consultations across both sites. Outcome measures include the number, type and severity of medication-related problems identified and resolved; medication adherence; and patient satisfaction. Brief structured interviews will be conducted with patients participating in the study to evaluate their experiences with the service. Staff collaboration and satisfaction with the service will be assessed.
Discussion
This intervention has the potential to optimise medication use in primary care clinics leading to better health outcomes. This study will provide data about the effectiveness of the proposed model for pharmacist involvement in Australian general practice clinics, that will be useful to guide further research and development in this area.
Trial registration
Australian New Zealand Clinical Trials Registry: ACTRN12612000742875
doi:10.1186/1472-6963-12-246
PMCID: PMC3470952  PMID: 22876813
Pharmacists; Primary healthcare; General practice; Multidisciplinary; Family practice
11.  Pharmacists’ Provision of Information to Spanish-speaking Patients: A Social Cognitive Approach 
Background
Hispanics with limited English proficiency face communication challenges that affect medication use and outcomes. Pharmacists are poised to help patients use medications safely and effectively, however scant research has explored factors that may impact pharmacists’ communication with Spanish-speaking patients (SSPs).
Objective
Guided by Social Cognitive Theory (SCT), the purpose of this study was to examine the relationships between pharmacy environmental factors, pharmacists’ cognition and pharmacists’ communication with SSPs.
Methods
A cross-sectional survey used a vignette to quantify the amount of information pharmacists would provide to a SSP. Pharmacy environmental factors (language-assistance resources, Spanish-speaking staff, and number of Spanish-speaking patients) and pharmacists’ cognition (self-efficacy beliefs and cultural sensitivity) that may influence communication also were assessed. The relationships between environmental factors, cognition and pharmacists’ communication with SSPs, including indirect relationships, were examined using composite indicator structural equation (CISE) modeling.
Results
Of the 183 respondents, the majority were white (91%) and male (63%) with a mean age of 47 years (SD=12.77). The CISE modeling revealed that the number of SSPs served by the pharmacy and the pharmacist's self-efficacy in communicating with SSPs were significantly directly associated with pharmacist's provision of information to SSPs. Two environmental factors (presence of interpreter services and Spanish-speaking staff) operated indirectly through self-efficacy to significantly impact the provision of information.
Conclusions
Study findings identify both environmental factors and cognition that could contribute to pharmacists’ communication behavior with SSPs. Thus, future interventions to improve pharmacists’ communication with SSPs may include training pharmacists to integrate interpretative services and Spanish-speaking staff into service delivery, as well as strengthening pharmacists’ self-efficacy beliefs.
doi:10.1016/j.sapharm.2012.02.003
PMCID: PMC4441301  PMID: 22554399
Pharmacists; Communication; Spanish-speaking patients
12.  Effect of Clinical Pharmacist Intervention on Medication Discrepancies Following Hospital Discharge 
Background
Medication discrepancies may occur at transitions in care and negatively impact patient outcomes.
Objective
To determine if involving clinical pharmacists in hospital care, medication reconciliation and discharge medication plan communication can reduce medication discrepancies with a prospective, randomized, blinded, controlled trial.
Setting
A large, tertiary care, academic medical center.
Method
The intervention consisted of clinical pharmacist medication reconciliation, patient education and improved communication of the discharge medication plan, as devised by the hospital physician and care team, to primary care physicians and community pharmacists. Medication discrepancies were identified by blinded research pharmacists who reviewed primary care physician and pharmacy records at discharge through 90 days post-discharge to create 30-day and 90-day medication lists. Main outcome measure: Rate of medication discrepancies compared across groups.
Results
A total of 592 subjects from internal medicine, family medicine, cardiology and orthopedic services were evaluated for this study. Clinically important medication discrepancies in the primary care physician record were different between groups 30 days after hospital discharge following a clinical pharmacist's intervention. The mean number of medication discrepancies per patient for the enhanced group being nearly half the number in the control group. However, this effect did not persist to 90 days post-discharge and did not extend to community pharmacy records.
Conclusion
The present study demonstrates the involvement of pharmacists in hospital care, medication reconciliation and discharge medication plan communication may affect the quality of the outpatient medical record.
doi:10.1007/s11096-014-9917-x
PMCID: PMC4026363  PMID: 24515550
medication discrepancies; Pharmacist Case Manager; Medication reconciliation; Transitions of Care; Medical Record; Pharmacy Record; Continuity of Care; hospital discharge; United States
13.  Pharmacists’ perspectives on promoting medication adherence among patients with HIV 
Objectives
To provide pharmacists’ perspectives on medication adherence barriers for patients with human immunodeficiency virus (HIV) and to describe pharmacists’ strategies for promoting adherence to antiretroviral medications.
Design
Multisite, qualitative, descriptive study.
Setting
Four midwestern U.S. states, from August through October 2009.
Participants
19 pharmacists at 10 pharmacies providing services to patients with HIV.
Intervention
Pharmacists were interviewed using a semistructured interview guide.
Main outcome measures
Barriers to medication adherence, pharmacist interventions, challenges to promoting adherence.
Results
Pharmacists reported a range of adherence barriers that were patient specific (e.g., cognitive factors, lack of social support), therapy related (e.g., adverse effects, intolerable medications), and structural level (e.g., strained provider relationships). They used a combination of individually tailored, patient-specific interventions that identified and resolved adherence barriers and actively anticipated and addressed potential adherence barriers. Pharmacist interventions included medication-specific education to enhance patient self-efficacy, follow-up calls to monitor adherence, practical and social support to motivate adherence, and patient referrals to other health care providers. However, the pharmacists faced internal (e.g., lack of time, lack of trained personnel) and external (e.g., insurance policies that disallowed patient enrollment in automatic prescription refill program) challenges.
Conclusion
Pharmacists in community settings went beyond prescription drug counseling mandated by law to provide additional pharmacy services that were tailored to the needs of patients with HIV. Given that many individuals with HIV are living longer, more research is needed on the effectiveness and cost effectiveness of pharmacists’ interventions in clinical practice, in order to inform insurance reimbursement policies.
doi:10.1331/JAPhA.2011.10190
PMCID: PMC4371784  PMID: 22068197
Clinical interventions; pharmacists; patient-centered care; barriers; medication adherence; health promotion; human immunodeficiency virus
14.  A role for pharmacists in community-based post-discharge warfarin management: protocol for the 'the role of community pharmacy in post hospital management of patients initiated on warfarin' study 
Background
Shorter periods of hospitalisation and increasing warfarin use have placed stress on community-based healthcare services to care for patients taking warfarin after hospital discharge, a high-risk period for these patients. A previous randomised controlled trial demonstrated that a post-discharge service of 4 home visits and point-of-care (POC) International Normalised Ratio (INR) testing by a trained pharmacist improved patients' outcomes. The current study aims to modify this previously trialled service model to implement and then evaluate a sustainable program to enable the smooth transition of patients taking warfarin from the hospital to community setting.
Methods/Design
The service will be trialled in 8 sites across 3 Australian states using a prospective, controlled cohort study design. Patients discharged from hospital taking warfarin will receive 2 or 3 home visits by a trained 'home medicines review (HMR)-accredited' pharmacist in their 8 to 10 days after hospital discharge. Visits will involve a HMR, comprehensive warfarin education, and POC INR monitoring in collaboration with patients' general practitioners (GPs) and community pharmacists. Patient outcomes will be compared to those in a control, or 'usual care', group. The primary outcome measure will be the proportion of patients experiencing a major bleeding event in the 90 days after discharge. Secondary outcome measures will include combined major bleeding and thromboembolic events, death, cessation of warfarin therapy, INR control at 8 days post-discharge and unplanned hospital readmissions from any cause. Stakeholder satisfaction will be assessed using structured postal questionnaire mailed to patients, GPs, community pharmacists and accredited pharmacists at the completion of their study involvement.
Discussion
This study design incorporates several aspects of prior interventions that have been demonstrated to improve warfarin management, including POC INR testing, warfarin education and home visits by trained pharmacists. It faces several potential challenges, including the tight timeframe for patient follow-up in the post-discharge period. Its strengths lie in a strong multidisciplinary team and the utilisation of existing healthcare frameworks. It is hoped that this study will provide the evidence to support the national roll-out of the program as a new Australian professional community pharmacy service.
Trial Registration
Australian New Zealand Clinical Trials Registry Number 12608000334303.
doi:10.1186/1472-6963-11-16
PMCID: PMC3040704  PMID: 21261998
15.  Enhanced medication management services in the community 
Canadian Pharmacists Journal : CPJ  2013;146(3):162-168.
Background:
Pharmacists are now receiving reimbursement by the Ontario government to do medication reviews for patients on 3 or more medications. However, they are often too busy in the community setting to thoroughly review medications with patients. Having a designated pharmacist to provide medication reviews could increase the number of reviews performed.
Methods:
Step 1 involved developing a business plan to determine the number of medication reviews that needed to be done to pay a pharmacist a full-time salary. Step 2 involved establishing the core elements of medication therapy management that included medication review, a medication-related action plan, documentation and follow-up. In step 3, eligible patients were called and invited to attend an appointment to review their medications with the pharmacist. Upon completion of the medication reviews, a random group of patients were requested to complete a satisfaction survey after the medication review.
Results:
Three hundred thirty-six patients received billable medication reviews from April 4 to July 27, 2012. Twenty-seven additional visits were performed as follow-up visits. Eighty pharmaceutical opinions met the eligibility criteria for billing. Fifteen patients received counselling for smoking cessation. Medication reviews were completed for 19 patients from 8 other pharmacies. Extra revenue was generated through the sales of replacements of expired products. An average of 2.08 drug-related problems per patients was identified. One hundred percent of the patients were very satisfied with the service.
Conclusion:
A full-time pharmacist position providing enhanced medication management services generated enough income to pay for a full-time pharmacist’s salary. The benefits to the patients were an increase in identification and resolution of drug-related problems, as well as an opportunity to receive disease state education and experience an improvement in disease states. Patients were extremely satisfied with the medication review process and the service provided to them. Can Pharm J 2013;146:162-168.
doi:10.1177/1715163513481315
PMCID: PMC3676208  PMID: 23795201
16.  Older Patient, Physician and Pharmacist Perspectives about Community Pharmacists’ Roles 
Objectives
To investigate older patient, physician and pharmacist perspectives about the pharmacists’ role in pharmacist-patient interactions.
Methods
Design
Eight focus group discussions.
Settings
Senior centers, community pharmacies, primary care physician offices.
Participants
Forty-two patients aged 63 and older, 17 primary care physicians, and 13 community pharmacists.
Measurements
Qualitative analysis of focus group discussions.
Results
Participants in all focus groups indicated that pharmacists are a good resource for basic information about medications. Physicians appreciated pharmacists’ ability to identify drug interactions, yet did not comment on other specific aspects related to patient education and care. Physicians noted that pharmacists often were hindered by time constraints that impede patient counseling. Both patient and pharmacist participants indicated that patients often asked pharmacists to expand upon, reinforce, and explain physician-patient conversations about medications, as well as to evaluate medication appropriateness and physician treatment plans. These groups also noted that patients confided in pharmacists about medication-related problems before contacting physicians. Pharmacists identified several barriers to patient counseling, including lack of knowledge about medication indications and physician treatment plans.
Conclusions
Community-based pharmacists may often be presented with opportunities to address questions that can affect patient medication use. Older patients, physicians and pharmacists all value greater pharmacist participation in patient care. Suboptimal information flow between physicians and pharmacists may hinder pharmacist interactions with patients and detract from patient medication management. Interventions to integrate pharmacists into the patient healthcare team could improve patient medication management.
doi:10.1111/j.2042-7174.2012.00202.x
PMCID: PMC3442941  PMID: 22953767
pharmacist-patient interactions; provider-patient communication; prescription medication; qualitative research methods
17.  Clinical pharmacy activities in chronic kidney disease and end-stage renal disease patients: a systematic literature review 
BMC Nephrology  2011;12:35.
Background
Chronic kidney disease (CKD) and end-stage renal disease (ESRD) represent worldwide health problems with an epidemic extent. Therefore, attention must be given to the optimisation of patient care, as gaps in the care of CKD and ESRD patients are well documented. As part of a multidisciplinary patient care strategy, clinical pharmacy services have led to improvements in patient care. The purpose of this study was to summarise the available evidence regarding the role and impact of clinical pharmacy services for these patient populations.
Methods
A literature search was conducted using the Medline, Embase and International Pharmaceutical Abstracts databases to identify relevant studies on the impact of clinical pharmacists on CKD and ESRD patients, regarding disease-oriented and patient-oriented outcomes, and clinical pharmacist interventions on drug-related problems.
Results
Among a total of 21 studies, only four (19%) were controlled trials. The majority of studies were descriptive (67%) and before-after studies (14%). Interventions comprised general clinical pharmacy services with a focus on detecting, resolving and preventing drug-related problems, clinical pharmacy services with a focus on disease management, or clinical pharmacy services with a focus on patient education in order to increase medication knowledge. Anaemia was the most common comorbidity managed by clinical pharmacists, and their involvement led to significant improvement in investigated disease-oriented outcomes, for example, haemoglobin levels. Only four of the studies (including three controlled trials) presented data on patient-oriented outcomes, for example, quality of life and length of hospitalisation. Studies investigating the number and type of clinical pharmacist interventions and physician acceptance rates reported a mean acceptance rate of 79%. The most common reported drug-related problems were incorrect dosing, the need for additional pharmacotherapy, and medical record discrepancies.
Conclusions
Few high-quality trials addressing the benefit and impact of clinical pharmacy services in CKD and ESRD patients have been published. However, all available studies reported some positive impact resulting from clinical pharmacist involvement, including various investigated outcome measures that could be improved. Additional randomised controlled trials investigating patient-oriented outcomes are needed to further determine the role of clinical pharmacists and the benefits of clinical pharmacy services to CKD and ESRD patients.
doi:10.1186/1471-2369-12-35
PMCID: PMC3166893  PMID: 21777480
18.  Adherence: a review of education, research, practice and policy in Spain 
Pharmacy Practice  2009;7(3):125-138.
Aims:
To describe medication adherence education, practice, research and policy efforts carried out by pharmacists in Spain in the last decade.
Methods:
A literature review using Medline and Embase was conducted covering the last ten years. Additional pharmaceutical bibliographic sources in Spain were consulted to retrieve articles of interest from the last decade. Articles were included if a pharmacist was involved and if medication adherence was measured or there was any direct or indirect pharmacist intervention in monitoring and/or improving adherence. Articles focusing on the development of tools for adherence assessment were collected. Pre- and post-graduate pharmacy training programs were also reviewed through the Spanish Ministry of Education and Science website. Information regarding policy issues was gathered from the Spanish and Autonomous Communities of Education and Health Ministries websites.
Results:
Pharmacists receive no specific training focused on adherence. There is no specific government policies for pharmacists in Spain related to medication adherence regardless of their practice setting. A total of 24 research studies met our inclusion criteria. Of these, 10 involved pharmacist intervention in monitoring and/or improving adherence and 14 assessed only adherence. Ten studies involved hospital pharmacists working in collaboration with another healthcare professional.
Conclusions:
At present in Spain, the investigative role of the pharmacist is not well developed in the area of medication adherence. Adherence improvement services provided to patients by pharmacists are not implemented in a systematic way. However, recent efforts to implement new initiatives in this area may provide the basis for offering new cognitive services aimed at improving patient adherence in the near future.
PMCID: PMC4139043  PMID: 25143789
Medication Adherence; Pharmacists; Spain
19.  Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study 
BMJ Open  2012;2(3):e000939.
Objectives
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Design
Qualitative study involving focus groups with members of the public.
Setting
The West of Scotland.
Participants
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Results
Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be ‘high risk’. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence.
Conclusion
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be ‘high risk’, unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
Article summary
Article focus
Why do the public access GPs for services, which are also available in community pharmacies?
What sort of services do the public trust community pharmacists to deliver?
What factors underpin greater public trust in GP services relative to community pharmacy services?
Key messages
Public trust in GPs was greater than that in pharmacists; many were reluctant to trust pharmacists to deliver unfamiliar ‘high-risk’ services.
Numerous system-based factors reinforce public trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments.
This study suggests that increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services could build public trust.
Strengths and limitations of this study
This is the first study to apply sociological perspectives of trust to understand public perspectives of community pharmacy.
The qualitative approach has allowed us to gather in-depth information in an under-researched area.
The study methodology limits generalisation, although theme saturation was achieved and the context of the study is explicitly defined.
doi:10.1136/bmjopen-2012-000939
PMCID: PMC3358628  PMID: 22586286
20.  A Retrospective Evaluation of Remote Pharmacist Interventions in a Telepharmacy Service Model Using a Conceptual Framework 
Telemedicine Journal and e-Health  2014;20(10):893-901.
Abstract
Objectives: This retrospective cross-sectional study evaluated a telepharmacy service model using a conceptual framework to compare documented remote pharmacist interventions by year, hospital, and remote pharmacist and across rural hospitals with or without an on-site rural hospital pharmacist. Materials and Methods: Documented remote pharmacist interventions for patients at eight rural hospitals in the Midwestern United States during prospective prescription order review/entry from 2008 to 2011 were extracted from RxFusion® database (a home-grown system, i.e., internally developed program at The Nebraska Medical Center (TNMC) for capturing remote pharmacist-documented intervention data). The study authors conceptualized an analytical framework, mapping the 37 classes of remote pharmacist interventions to three broader-level definitions: (a) intervention, eight categories (interaction/potential interaction, contraindication, adverse effects, anticoagulation monitoring, drug product selection, drug regimen, summary, and recommendation), (b) patient medication management, two categories (therapy review and action), and (c) health system-centered medication use process, four categories (prescribing, transcribing and documenting, administering, and monitoring). Frequencies of intervention levels were compared by year, hospital, remote pharmacist, and hospital pharmacy status (with a remote pharmacist and on-site pharmacist or with a remote pharmacist only) using chi-squared test and univariate logistic regression analyses, as appropriate. Results: For 450,000 prescription orders 19,222 remote pharmacist interventions were documented. Frequency of interventions significantly increased each year (36% in 2009, 55% in 2010, and 7% in 2011) versus the baseline year (2008, 3%) when service started. The frequency of interventions also differed significantly across the eight hospitals and 16 remote pharmacists for the three defined intervention levels and categories. Remote pharmacist interventions at hospitals with an on-site and remote pharmacist (n=12,141) versus those with a remote pharmacist alone (n=7,081) were significantly more likely to be (1) patient-centered, (2) related to “actionable” medication management recommendations (unadjusted odds ratio [OR]=1.12), and (3) related to the “transcribing” (OR=1.47) and “prescribing” (OR=1.40) steps of the health system-centered medication use process level (all p<0.01). Conclusions: This is one of the first studies to demonstrate the patient- and health system-centered nature of pharmaceutical care delivered via a telepharmacy service model by evaluating documented remote pharmacist interventions with an analytical framework.
doi:10.1089/tmj.2013.0362
PMCID: PMC4188381  PMID: 24611489
pharmacy; telemedicine; medication records; e-health; policy
21.  Care Providers’ Satisfaction with Restructured Clinical Pharmacy Services in a Tertiary Care Teaching Hospital 
Background:
At the time this study was undertaken, clinical pharmacy services at the authors’ institution, a tertiary care teaching hospital, were largely reactive in nature, with patients and units receiving inconsistent coverage.
Objective:
To develop an evidence-based model of proactive practice and to evaluate the satisfaction of pharmacists and other stakeholders after restructuring of clinical pharmacy services.
Methods:
The literature was reviewed to determine a core set of pharmacist services associated with the greatest beneficial impact on patients’ health. On the basis of established staffing levels, the work schedule was modified, and pharmacists were assigned to a limited number of patient care teams to proactively and consistently provide these core services. Other patient care teams continued to receive reactive troubleshooting-based services, as directed by staff in the pharmacy dispensary. A satisfaction survey was distributed to all pharmacists, nurses, and physicians 18 months after the restructuring.
Results:
Of the 26 pharmacists who responded to the survey, all agreed or strongly agreed that the restructuring of services had improved job satisfaction and patient safety and that other health care professionals valued their contribution to patient care. Nurses and physicians from units where pharmacists had been assigned to provide proactive services perceived pharmacist services more favourably than those from units where pharmacist services were reactive. Pharmacists, nurses, and physicians all felt that proactive pharmacist services should be more widely available. Challenges reported by pharmacists included increased expectations for documentation and guilt about “cutting back” services where they had previously been provided.
Conclusions:
Restructuring clinical pharmacy services in an evidence-based manner improved pharmacists’ satisfaction and created demand from other stakeholders to provide this level of service for all patients.
PMCID: PMC2858499  PMID: 22478965
clinical pharmacy; restructuring; tertiary care hospital; evidence-based; practice delivery; pharmacie clinique; restructuration; hôpital de soins tertiaires; données probantes; prestation de services
22.  Stakeholder experiences with general practice pharmacist services: a qualitative study 
BMJ Open  2013;3(9):e003214.
Objectives
To explore general practice staff, pharmacist and patient experiences with pharmacist services in Australian general practice clinics within the Pharmacists in Practice Study.
Design
Qualitative study.
Setting
Two general practice clinics in Melbourne, Australia, in which pharmacists provided medication reviews, patient and staff education, medicines information and quality assurance services over a 6-month period.
Participants
Patients, practice staff and pharmacists.
Method
Semi-structured telephone interviews with patients, focus groups with practice staff and semi-structured interviews and periodic narrative reports with practice pharmacists. Data were analysed thematically and theoretical frameworks used to explain the findings.
Results
34 participants were recruited: 18 patients, 14 practice staff (9 general practitioners, 4 practice nurses, 1 practice manager) and 2 practice pharmacists. Five main themes emerged: environment; professional relationships and integration; pharmacist attributes; staff and patient benefits and logistical challenges. Participants reported that colocation and the interdisciplinary environment of general practice enabled better communication and collaboration compared to traditional community and consultant pharmacy services. Participants felt that pharmacists needed to possess certain attributes to ensure successful integration, including being personable and proactive. Attitudinal, professional and logistical barriers were identified but were able to be overcome. The findings were explained using D'Amour's structuration model of collaboration and Roger's diffusion of innovation theory.
Conclusions
This is the first qualitative study to explore the experiences of general practice staff, pharmacists and patients on their interactions within the Australian general practice environment. Participants were receptive of colocated pharmacist services, and various barriers and facilitators to integration were identified. Future research should investigate the feasibility and sustainability of general practice pharmacist roles.
doi:10.1136/bmjopen-2013-003214
PMCID: PMC3773653  PMID: 24030867
Primary Care; Qualitative Research; Health Services Administration & Management
23.  Medication reviews in the community: results of a randomized, controlled effectiveness trial 
Aims
To examine the effectiveness of a multidisciplinary service model delivering medication review to patients at risk of medication misadventure in the community.
Methods
The study was carried out in three Australian states; Queensland, New South Wales and Western Australia, and conducted as a randomized, controlled effectiveness trial with the general practitioner (GP) as the unit of randomization. In total, 92 GPs, 53 pharmacists and 400 patients enrolled in the study. The multidisciplinary service model consisted of GP education, patient home visits, pharmacist medication reviews, primary healthcare team conferences, GP implementation of action plans in consultation with patients, and follow-up surgery visits for monitoring. Effectiveness was assessed using the four clinical value compass domains of (i) functional status, (ii) clinical outcomes, (iii) satisfaction and (iv) costs. The domains of functional status (assessed by the health-related quality of life measure SF-36 subscales) and clinical outcomes (as assessed by adverse drug events (ADEs), number of GP visits, hospital services and severity of illness) were measured at baseline and endpoint. Satisfaction was measured by success in implementation and by participant satisfaction at endpoint, and costs (as assessed using medication and healthcare service costs, less intervention costs) were measured preintervention and during the trial. In addition, process evaluation was conducted for intervention patients, in which problems and recommendations from the medication reviews were described.
Results
The model was successfully implemented with 92% of intervention GPs suggesting that the model had improved the care of participating patients, a view shared by 94% of pharmacists. In addition, positive trends in clinical outcomes (ADEs and severity of illness) and costs (an ongoing trend towards reduction in healthcare service costs) were evident, although the trial was limited to a 6-month intervention time. No differences between intervention and control groups were identified for the health-related quality of life domain. The cost–effectiveness ratio for the intervention based on cost savings, reduced adverse events and improved health outcomes was small. The most common problems identified in the medication reviews were potential adverse drug reactions, suboptimal monitoring and adherence/lack of concordance issues. In total, 54.4% of recommendations were enacted, and 23.9% were implemented precisely as recommended in the medication review. Follow-up evaluation showed that 70.9% of actions had a positive outcome, 15.7% no effect and 3.7% had a negative outcome.
Conclusions
Most studies emphasize efficacy and the best achievable clinical outcomes rather than whether an intervention will be effective in practice. The current trial showed that three of the four domains in the clinical value compass showed trends of improvement or were indeed improved in the relatively short follow-up period of the trial, suggesting that a service based on this model could achieve similar benefits in practice. A domiciliary medication review programme similar to this model has now been implemented into national Australian practice, where GPs and pharmacists are reimbursed by the Australian government for the provision of these services.
doi:10.1111/j.1365-2125.2004.02220.x
PMCID: PMC1884656  PMID: 15563363
clinical value compass; community pharmacy services; effectiveness trial; home care services; patient care team; randomized controlled trials
24.  Effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings 
Background
The pharmaceutical care approach serves as a model for medication review, involving collaboration between GPs, pharmacists, patients, and carers. Its use is advocated with older patients who are typically prescribed several drugs. However, it has yet to be thoroughly evaluated.
Aim
To estimate the effectiveness of pharmaceutical care for older people, shared between GPs and community pharmacists in the UK, relative to usual care.
Design of study
Multiple interrupted time-series design in five primary care trusts which implemented pharmaceutical care at 2-month intervals in random order. Patients acted as their own controls, and were followed over 3 years including their 12 months' participation in pharmaceutical care.
Setting
In 2002, 760 patients, aged ≥75 years, were recruited from 24 general practices in East and North Yorkshire. Sixty-two community pharmacies also took part. A total of 551 participants completed the study.
Method
Pharmaceutical care was undertaken by community pharmacists who interviewed patients, developed and implemented pharmaceutical care plans together with patients' GPs, and thereafter undertook monthly medication reviews. Pharmacists and GPs attended training before the intervention. Outcome measures were the UK Medication Appropriateness Index, the Short Form–36 Health Survey (SF-36), and serious adverse events.
Results
The intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes. Although the mental component of the SF-36 decreased as study participants become older, this trend was not affected by pharmaceutical care.
Conclusion
The RESPECT model of pharmaceutical care (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) shared between community pharmacists and GPs did not significantly change the appropriateness of prescribing or quality of life in older patients.
doi:10.3399/bjgp09X473295
PMCID: PMC2801801  PMID: 19995493
health services for the aged; medication therapy management; pharmaceutical care; polypharmacy; randomised controlled trial
25.  A consumer-targeted, pharmacist-led, educational intervention to reduce inappropriate medication use in community older adults (D-PRESCRIBE trial): study protocol for a cluster randomized controlled trial 
Trials  2015;16:266.
Background
Medication safety for older persons represents an ongoing challenge. Inappropriate prescriptions – those with a high risk of evidence-based harm – persist in up to 25 % of seniors, and account for a significant proportion of avoidable emergency department visits. This project is the sequel to the EMPOWER study, in which a novel consumer-targeted written knowledge transfer tool aimed at empowering older adults to act as drivers of benzodiazepine de-prescription resulted in a 27 % reduction of inappropriate benzodiazepine use at 6-month follow-up (number needed to treat (NNT) = 4). Failure to discontinue in the EMPOWER study was attributable to re-emerging symptoms among participants, prescribing inertia, and lack of knowledge and skills for substituting alternate therapy among physicians and pharmacists. To maximize de-prescription of inappropriate therapy, educational medication-risk reduction initiatives should be tested that simultaneously include patients, physicians and pharmacists. The objective of this trial is to: 1) test the beneficial effect of a new de-prescribing paradigm enlisting pharmacists to transfer knowledge to both patients and prescribers in a 2-pronged approach to reduce inappropriate prescriptions, compared to usual care and 2) evaluate the transferability of the EMPOWER study concept to other classes of inappropriate prescriptions.
Methods
We intend to conduct a 3-year pragmatic cluster randomized parallel-group controlled trial to test the effect of the new de-prescribing intervention compared to usual care for reducing 4 classes of inappropriate prescriptions from the 2012 Beers criteria among 450 community-dwelling older adults with polypharmacy. Inappropriate prescriptions will include benzodiazepines, sulfonylurea hypoglycemic agents, first generation antihistamines and non-steroidal anti-inflammatory drugs. The study population is community-dwelling older adults recruited from community pharmacies in Quebec, Canada. The intervention was developed based on a systematic review of the evidence for each medication. Participants in the experimental group will receive the written educational program following randomization and have their pharmacist send their physicians an evidence-based pharmaceutical opinion to recommend de-prescription and be followed for a year. The control group will be wait-listed for 6 months.
Discussion
System change to effectively reduce medication risk among community-dwelling seniors requires a coordinated approach targeting physicians, pharmacists and patients. This trial will test the feasibility and effectiveness of a tripartite approach to de-prescribing.
Trial registration
Registered via ClinicalTrials.gov on 31 January 2014, identifier: NCT02053194.
doi:10.1186/s13063-015-0791-1
PMCID: PMC4512085  PMID: 26058676
Patient education; Inappropriate prescription; Pharmaceutical opinion; Cognition disorders/drug therapy; Polypharmacy

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