Investigating medication review services provided by community pharmacists

Background: In recent years, pharmacists’ roles have expanded to include more patient-centred services such as medication review and prescribing. In 2006, the Pharmacy Council of New Zealand proposed a framework for pharmacy services which consisted of four tiers of patient-focussed services. The services were (1) Medicines Provision (2) Medicines Use Review (MUR) (3) Medicines Therapy Assessment (MTA) and (4) Comprehensive Medicines Management (CMM) which may include pharmacist prescribing. These new services were developed with different purposes and aims and were intended to be conducted in close collaboration with general practitioners (GPs). Aims: This thesis aims to examine medication review services conducted locally and overseas and examine the effects of different types of medication review on the patient care process and patient outcomes. This thesis also aims to explore GPs’ perceptions of different types of medication review services and future services such as pharmacist prescribing in New Zealand. Methods: MUR services that were provided in a locality in New Zealand and conducted from November 2007 until December 2011 were assessed through a retrospective review of MUR patients’ records. The services’ outcomes were evaluated and factors that may influence the outcomes were investigated using multilevel mixed-effects logistic regression. Types of drug related problems (DRPs) identified by the pharmacists during MUR were categorised according to the DRP classification scheme v6.2 by the Pharmaceutical Care Network Europe (PCNE). In addition, a systematic review and meta-analysis of fee-for-service medication review services was conducted to evaluate the outcomes of the services. The outcomes were also quantified according to types of medication review e.g. MUR vs MTA-like services. Following that, face-to-face, semi-structured interviews were undertaken with GPs from two localities, whose patients had and had not undergone a pharmacist-led MUR service. GPs were asked for their opinions of pharmacists’ provision of MUR, MTA and prescribing and some other services and the data were analysed thematically using NVivo 8 and grouped by strengths, weaknesses, opportunities and threats (SWOT) categories. Results: A total of 353 MUR patients’ records were evaluated. MUR was found to improve patients’ knowledge, perceptions of, and adherence to medications. Several factors such as gender, ethnicity and duration of engagement with the service were found to predict patients' outcomes. A total of 886 DRPs were identified by pharmacists during the review period. Of this, 160 (18.1%) of the DRPs identified were clinical interventions and were perceived as a MTA level service that went beyond the practice of MUR. From the systematic review and meta-analysis, MTA-like services were found to have a significant impact on patient outcomes by attainment of target clinical biomarkers and reduced hospitalisation but this was not found in MUR-like services. From the interviews, GPs were found to be more accepting of pharmacists providing MUR and MTA but less supportive of pharmacist prescribing. The opportunities for community pharmacists included GPs’ openness to work in close collaboration with pharmacists particularly if services were integrated into GPs’ practices. The perceived threats to the services included perceptions from the GPs that such services could increase GPs’ workloads with limited benefits to patients. Conclusions: MUR and MTA were found to have different effects on patient outcomes. Although the MUR service in the locality studied had positive effects on patients’ knowledge, perceptions of, and adherence to medications, the overview of such services overseas did not report significant results on patients’ clinical outcomes. Since the service was not intended to provide the clinical support required by patients, patients who receive only MUR may potentially miss out on optimal care. Although GPs were accepting of both MUR and MTA, they had some concerns about certain aspects of the services. However, GPs’ willingness to work collaboratively with pharmacists was seen as an opportunity for optimal medication-related patient-care and could overcome these concerns