Br J Clin Pharmacol. 2012 Jul; 74(1): 16–33. This article systematically reviews the literature on the impact of collaboration between pharmacists and general practitioners and describes its effect on patients' health. A systematic literature search provided 1041 articles. After first review of title and abstract, 152 articles
remained. After review of the full text, 83 articles were included. All included articles are presented according to the following variables: (i) reference; (ii) design and setting of the study; (iii) inclusion criteria for patients; (iv) description of the intervention; (v) whether a patient interview was performed to involve patients' experiences with their medicine-taking behaviour; (vi) outcome; (vii) whether healthcare professionals received additional training; and (viii) whether
healthcare professionals received financial reimbursement. Many different interventions are described where pharmacists and general practitioners work together to improve patients' health. Only nine studies reported hard outcomes, such as hospital (re)admissions; however, these studies had different results, not all of which were statistically significant. Randomized controlled trials should be able to describe hard outcomes, but large patient groups will be needed to perform such studies.
Patient involvement is important for long-term success. Keywords: family physician, interprofessional relations, patient care, pharmaceutical care, pharmaceutical services, pharmacist To provide best pharmaceutical care practice, it is important that all relevant persons are involved and work together as a healthcare team
[1], [2]. As a result, healthcare providers should have a complete patient and medical record. Besides medical information from healthcare providers, a consultation round with the patient is also necessary to determine patients' problems and patients' needs. Active participation of
patients during treatment could help to achieve better patient outcomes [3], [4]. In primary care, the triangle of the pharmacist–general practitioner (GP)–patient is important for providing optimal pharmaceutical care. According to the definition of Cipolle et
al., pharmaceutical care is ‘a patient-centered practice in which the practitioner assumes responsibility for a patient's drug-related needs and is held accountable for this commitment’[5]. An important tool for pharmaceutical care is regular medication reviews or medication reconciliation next to the assessment of patient needs and the development of a care plan. A medication
review is defined as ‘a structured, critical examination of a patient's medicines with the objective of reaching an agreement with the patient about treatment, optimizing the impact of medicines, minimizing the number of medication-related problems and reducing waste’[6]. Medication reconciliation is defined as ‘the process of obtaining and maintaining a complete and accurate list of the current
medication use of a patient across healthcare settings’[7]. In 2002, the Medicines Partnership defined four levels of medication review [6]
(Figure 1). An ad hoc review (level 0) consists of an isolated question to a patient. A prescription review (level 1) is a review of a patient's medicine by a pharmacist. A treatment review (level 2) requires cooperation between pharmacist and GP (or medical specialist) to review a patient's medicines with the
patient's full notes. Finally, a clinical medication review (CMR; level 3) requires face-to-face cooperation between pharmacist and/or GP and the patient in order to review a patient's medicines and conditions. When performing a higher level of medication review, cooperation must increase. In 2008, the four levels were reviewed and redefined to three types in order to focus on the purpose of medication review
[8]. One important reason was that medicines use review (MUR), a new development in medication review services, did not fit within the previously defined levels of medication review. A MUR is conducted with the patient (level 3) but without access to the patient's full notes (level 2). In this new classification, prescription review (type 1), concordance and compliance review (type 2) and clinical
medication review (type 3) are defined (Table 1) [8]. However, we believe not all different kinds of medication review are covered within these new defined types of medication reviews, e.g. the former level 2, treatment review, where a
pharmacist cooperates with a GP to review the patient's medicines with the patient's full notes. Several classifications of medication review activities are being used but none covers all different activities. One similarity is that both the highest level and/or type of medication review requires the patient's presence. We therefore decided to focus on the participation of the patient. Different levels of medication review (reproduced with the permission of the authors) [6] Table 1Characteristics of types of medication reviews [8]
So far, there are no systematic reviews available that compare the different types of cooperation between family doctors and pharmacists and their impact on patient outcomes. This article systematically reviews the literature on the impact of collaboration between pharmacists and GPs and describes their outcomes on patients' health. MethodsA systematic literature search was performed in the databases PubMed and Embase (period until 16 June 2011) with keywords described in Table 2. Abstracts and articles were reviewed by two authors independently (M.M.E.G and J.J.deG.). Articles were first reviewed based on title and abstract (n = 1041) and second on full text (n = 152). Only English and Dutch written articles were included. Full-text articles were excluded based on language (n = 2), lack of cooperation (n = 11), lack of patient outcomes (n = 41), short communication, e.g. letter, summary or abstract (n = 15), and duplicate articles (n = 7). Finally, seven additional articles were included, five from references from other articles and two that were not available in the databases at time of the literature search. In total, 83 articles were included (Figure 2). The measure of agreement between the two reviewers, defined as Cohen's kappa (κ), was calculated using SPSS 18.0.3. Table 2Keywords used for literature search
ResultsThe two authors, who reviewed the titles and abstracts, reached strong agreement (κ= 0.766). All included articles after review of full text (n = 83) are presented in Table 3 according to the following variables: (i) reference; (ii) design and setting of the study; (iii) inclusion criteria for patients; (iv) description of the intervention; (v) whether a patient interview was performed to involve patients' experiences with their medicine-taking behaviour; (vi) outcome; (vii) whether healthcare professionals received additional training; and (viii) whether healthcare professionals received financial reimbursement. Articles are arranged in alphabetical order. Table 3Included articles (n = 83)
The 83 included articles describe results from 77 studies. Most studies were performed in Europe (n = 40), followed by the USA/Canada (n = 19) and Australia/New Zealand (n = 18). A majority of studies (n = 60) describe patient involvement using a patient interview or consultation (either at home or at the pharmacy/GP practice). About one-third of the studies (26 of 77) provided information on additional training, mostly for participating pharmacists. Only 11 studies reported financial reimbursement for participating healthcare providers. The amounts differed and were not always mentioned. Studies with a high level of evidence, such as randomized controlled trials, showed more significant results when compared with studies having a lower level of evidence, such as retrospective observational studies. Not all studies were able to conclude with hard outcomes, such as decrease in hospital admissions or costs. Only nine studies reported outcomes on hospital admissions. When we focused more on these studies, we found some differences. Farris et al. [9] showed a nonsignificant decrease in hospital admissions. A single-group pre–post design was used, and 199 patients were included (no power calculation was performed). Each primary healthcare team (PHCT) received training, but team pharmacists were generally not patients' dispensing pharmacists. An average of 3.9 issues were defined per patient, and an average of 59% of issues were resolved. However, these numbers showed large differences between the six PHCTs. Six studies used a randomized controlled trial (RCT) design. Graffen et al. [10] showed no differences in hospitalization rates among 402 included patients (determined by power calculation). No additional training was provided and no patient interview performed. Hospitalizations were determined by asking patients. Holland et al. [11] found a statistically significant increase in hospital admissions. A total of 872 patients were included (determined by power calculation). Pharmacists received a 2 day training course. Leendertse [12] found a nonsignificant decrease in medication-related hospital admissions; however, the intervention did show a statistically significant result for patients with five or more diseases. In this RCT, 674 patients were included (aim 14 200 based on power calculation). Pharmacists received additional training. Lenaghan et al. [13] found no differences in hospital admissions among 136 included patients (aim 164 based on power calculation). Pharmacists did not receive additional training but were experienced in performing home medicines reviews (HMRs). Makowsky et al. [14] found a statistically significant decrease in hospital admissions after 3 but not after 6 months. A total of 452 patients were included (aim 650 based on power calculation). The intervention was performed by experienced pharmacists who did not receive additional training. Nazareth et al. [15] found no differences in hospital admissions among 362 included patients (aim 390 based on power calculation). No additional training was provided for participating healthcare providers. Two cohort studies performed by Roughead et al. [16], [17] showed a statistically significant decrease in hospitalization rates for specific patient groups. Their first study included 273 patients exposed to an HMR and showed a 45% reduction in hospitalization for heart failure patients [16]. Their second study included 816 patients exposed to an HMR and showed 79% reduction in hospitalization for warfarin-associated bleeding [17]. Both studies were performed by experienced pharmacists, and no additional training was provided. Other significant results found were decreases in number of drug-related problems, improved prescribing of medication, improved quality of life scores, improved medication appropriateness index scores, increased compliance and patient knowledge, and improved clinical values, e.g. cholesterol levels. Most studies described positive outcomes on satisfaction. Healthcare providers and patients were satisfied when they were involved in projects. Studies also showed that when cooperation between healthcare providers and patients occurred, more drug-related problems were defined and solved. DiscussionA recent Cochrane review focused on health-related outcomes of clinical pharmacy services [18]. Pharmacist interventions resulted in improvement in most clinical outcomes, but these were not always statistically significant. The Cochrane review only describes pharmacist interventions, whereas our review focuses on interventions with cooperation between pharmacists and GPs. Only nine studies report hard outcomes, such as hospital (re)admissions [9]–[17]. Three studies show a significant decrease in hospital (re)admissions [14], [16], [17], and one study shows an increase in hospital admissions [11]. The intervention described by Holland et al. is performed by a review pharmacist [11]. Also, the intervention by Farris et al. [9] was not performed by the patients' own pharmacist, whereas the other seven studies did include cooperation between the patients' own pharmacist and GP. All studies with no differences in hospital admissions provided no additional training to pharmacists [10], [13], [15]; however, one study did mention that the intervention was performed by experienced pharmacists [13]. Graffen et al. [10] determined hospitalization rates by asking patients, which could result in recall bias. Other studies did provide additional training to pharmacists or mentioned that pharmacists were experienced. This could mean that the pharmacists involved in the selected studies were not able to perform an adequate medication review or medication reconciliation without additional training. Not all studies managed to include sufficient patient numbers necessary according to their power calculation. Two studies did report a decrease in hospital admissions, which could be significant after including higher patient numbers [12], [14] A subanalysis from Leendertse et al. [12] did show a significant decrease in medication-related hospital admissions for patients with ≥5 diseases. In order to retrieve hard outcomes, such as hospital (re)admissions, randomized clinical trials with large numbers of patients are needed. In most studies, numbers are too small to be able to study hard outcomes. Also, the level of cooperation and communication between healthcare providers is important. Denneboom et al. [19] performed a study using level 2 medication review and concluded that feedback in personal contact led to significantly more medication changes when compared with written feedback. When there is personal contact, healthcare providers can motivate their opinion on possible medication changes and, together, might choose a different intervention than they originally had suggested instead of rejecting the proposed intervention outright. When the patient is also involved, the intervention will have a higher chance of long-term success. When patients agree with the proposed intervention, they will be more motivated to change [4], [20]–[22]. The quality of collaboration is also important. Isetts et al. [23] performed a quality assessment of therapeutic determinations made by pharmacists. Decisions made by healthcare providers were found to be clinically credible based on the evaluations and comments of a peer review panel. When pharmaceutical care practitioners collaborate with physicians to provide drug therapy management services, this may help to reduce drug-related morbidity and improve therapeutic outcomes. Several classifications of medication review activities are used, but none of the classification systems is able to cover all different kinds of activities. In order to compare different activities, it is important to develop one classification system that can be used for all different activities performed throughout the whole world. Most studies performed focused on elderly patients with multiple morbidities using multiple medicines (polypharmacy). These patients are at higher risk of complications and would benefit most from a periodic CMR [24], [25]. In many countries, clinical pharmacologists are also involved in CMRs; these studies were not included in this review, because the focus is on pharmacists and GPs as healthcare providers, with whom patients have a relationship. Besides study design and patient outcomes, we looked at additional training for healthcare providers and financial reimbursement. Performing services such as medication review or medication reconciliation takes time. When performed at a higher level, time investment will increase. We question whether all healthcare providers have sufficient skill and experience to perform these services, knowing it involves complex patients with multiple morbidities and polypharmacy. In about one-third of the included studies, additional training was provided to participating healthcare providers, usually for pharmacists. This training usually concerned education about specific diseases and communication skills. Twelve studies mention that they did not provide additional training, but the studies were performed by accredited and experienced (clinical) pharmacists. Of these studies, six were performed in Australia, where the service called home medicines review (HMR) can only be performed by accredited pharmacists who are reimbursed for their services. Australia is well known for the development and implementation of HMRs. Some studies focused on cost-effectiveness of medication review services, but none could show significant results. A recent study by Perez et al. [26] showed economic evaluations of clinical pharmacy services from 2001 to 2005. A median benefit-to-cost ratio of 4.81:1 was found, meaning that for every $1 spent a $4.81 reduction in costs or other economic benefits was achieved. When other healthcare providers besides pharmacists, e.g. GPs, are involved, costs of the intervention will increase without knowing what this means for the achieved benefits. More research on cost-effectiveness of multidisciplinary interventions is necessary. The strength of this article is its use of a systematic literature search. However, we did find five relevant articles outside the performed search, which may mean we missed other articles. One reason for this could be that certain articles do not have well-defined keywords or that cooperation is not explicitly mentioned in the title or abstract. We excluded two articles based on their language (Norwegian and French). We do not believe this influenced our results. We recommend that future research should include a large randomized clinical trial with high patient numbers focused on hard outcomes, e.g. hospital (re)admissions and cost-effectiveness. With such a study, healthcare providers would be able to show their professional skills and how they can provide benefit to patients at high risk. This will make it easier to determine the necessary additional skills and proper reimbursement for time spent. ConclusionsMany different interventions are described where pharmacists and GPs work together to improve patients' health. Besides results on patient satisfaction, drug-related problems, quality of life and clinical values, fewer studies report hard outcomes, and results are not all comparable. Randomized controlled trials should be able to describe hard outcomes, but large patient groups will be needed to perform such studies. Patient involvement is important for motivation to change and for a long-term effect of the proposed intervention. AcknowledgmentsWe thank Truus van Ittersum, library services of Research Institute SHARE, for her help with the systematic literature search. We thank Timothy Broesamle for editing this article. Competing InterestsThere are no competing interests to declare. REFERENCES2. Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169:894–900. [PubMed] [Google Scholar] 3. Michie S, Miles J, Weinman J. 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The doctor can also remove outdated medicine and add new ones. The assessment can reveal other helpful information, like if the patient is not taking the medication due to uncomfortable side effects.
Why does my medication need to be reviewed?Why are medication reviews so important? Medication reviews identify opportunities to help you get the best out of the medicines you're taking, to help you understand what they do and why you're taking them, to switch you to different medicines – or sometimes to stop medicines that are no longer right for you.
How long does it take to verify prescription?The Fairness to Contact Lens Consumers Act and the Rule give prescribers eight business hours to verify a prescription regardless of when the prescriber gets a properly completed verification request.
What does it mean when your prescription is in process?Refill in Process: This status means the refill request is being processed by the pharmacy. The entire row will be bolded when the refill is being processed.
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