pharmacist-led medication review has the capacity to identify and resolve pharmaceutical care issues and may have some impact on the use of other health services.
Objective — To investigate the usefulness of a system for classifying pharmaceutical care issues (PCIs), defined in Scottish practice guidelines as “an element of a pharmaceutical need which is addressed by the pharmacist,” which were identified during the delivery of pharmaceutical care in a primary care setting. Method é The classification system had 12 categories, each with a definition and examples reflecting the primary care setting to assist in assigning categories to individual PCIs. There was no category of “other” or “miscellaneous”. The system was used by two clinical pharmacists in a study involving 332 patients aged 65 years or over collecting four or more medicines regularly. The point at which PCIs were identified and resolved, the drugs involved and the actions required to resolve them were analysed for each type of PCI. Setting — Six randomly selected medical practices in the Grampian region of Scotland. Key findings — All 2,586 PCIs identified were successfully assigned one category within this classification system. The most commonly occurring types of PCI were “potential adverse drug reaction”, “need for monitoring”, “potentially ineffective therapy” and “need for education.” Most PCIs classed as “potential adverse drug reaction” and “need for monitoring” were identified from the prescription record. A third of “potentially ineffective therapy” PCIs, plus most PCIs classed as “drug use — no indication” and “indication — no treatment” were identified from medical records. Patient interview identified most of the PCIs categorised as “need for education,” “suspected adverse drug reaction” and “actual compliance issue.” Resolving the “need for education,” “suspected/actual compliance issue” and “out of date medicines” PCIs mostly involved the patient, whereas those involving changes to prescribed therapy or monitoring required contact with a health care professional. Conclusion — The classification system was comprehensive in its coverage of PCIs arising from clinical pharmacists' direct patient care activities in a primary care setting. While the system requires further development and testing, it would appear to be a useful tool for researchers and practitioners to use in describing and comparing PCIs in different studies and using different practices.
Patient knowledge was assessed at initial clinic visits. Despite counselling in hospital, this was unsatisfactory. Clinic time was devoted to reinforcing understanding. Review at three months showed improved knowledge levels.The direct costs to the practice of the clinic, including the cost of the pharmacist, the tests, and the cost of the coagulometer, were less than the £35 charged to fundholders for each hospital appointment. Surgery attendance cost less for 48% of patients and more for 4%. Travelling time was less for 64% and greater for 20%. Most patients lived near the surgery, eliminating the need for an estimated 27 ambulance trips a year. Patients were seen within 10 minutes of their surgery appointment time, while hospital waits routinely exceeded one hour.Patients preferred surgery management, and most preferred a pharmacist to rotating junior doctors. General practitioners believed that the quality of care improved. CommentAnticoagulant control requires skills which clinical pharmacists have. This study shows that if general practitioners-are willing to devolve management to pharmacists then good therapeutic control is achievable in the surgery. In addition, liaison between general practitioners and pharmacists reduces the risk of toxicity and treatment failure, and patient knowledge can be improved through counselling. The management of small numbers (about 30 patients at any time) proved to be cost effective. The patients also welcomed reduced waiting times and travelling costs. The elderly and those disabled by cardiovascular diseases benefited particularly, making this model appropriate to extend the benefits of warfarin to patients with non-rheumatic atrial fibrillation.Funding: Scottish Office Home and Health Department.The project was part of a study to assess the effects of integration of a pharmnacist into a fundholding GP Practice.Conflict ofinterest: None.
A recent Audit Commission report into general practice prescribing identifies areas where general practitioner and pharmacist collaboration could be beneficial. Two such areas are formulary development and repeat prescribing review. Increased generic prescribing is encouraged in the report and in central priorities for Scottish Health Boards. This study was designed to develop and assess the effects on prescribing, of a practice formulary and a procedure for change to generic name prescribing. A practice formulary, standards for generic name prescribing and an approach to prescribing review were agreed, developed and implemented. Formulary compliance and the extent of prescribing generically and of changes to generic prescriptions were assessed by prospective prescription monitoring. Consultations resulting in a prescription reduced from 69% to 59% and 80% of acute prescribing events were met from 144 formulary medicines. Rapid change to generic name prescriptions was achieved without patient complaints and the overall generic prescribing level increased from 57% to 68%. Eighty percent of all new prescriptions were generic.
Focal points □ Implementing pharmaceutical care plans requires pharmacists to interact with both patients and health care professionals □ The actions involved in implementation for the majority of drug classes require contact with other health care professionals □ Requests for monitoring make up a substantial proportion of these contacts □ Authorising pharmacists to make requests directly to appropriate staff may enhance pharmaceutical care without increasing general practitioners' workload.
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