Karen A. Maes1, Kurt E. Hersberger1, Markus L. Lampert1,2
1Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056 Basel, Switzerland
2Institute of Hospital Pharmacy, Solothurner Spitäler, Olten, Switzerland
International Journal of Clinical Pharmacy Submitted 11th November 2016
PhD Thesis Karen Maes 99 Abstract
Background: During dispensing of prescribed medicines, pharmacists frequently encounter technical and clinical problems that require a pharmaceutical intervention (PI).
Objective: To describe the PIs during dispensing of prescribed medicines in community pharmacies, and to investigate patient-reported problems with the prescribed medicines.
Method: Twenty-one pharmacists each collected 30 prescriptions requiring a PI on five selected days within a five-week period. All PIs were classified using the PharmDISC system.
Results: Of all 430 PIs, 242 PIs (56.3%) had a clinical cause and 188 PIs (43.7%) a technical cause.
Patient-reported problems (n=99, 23.0%) were common. Pharmacists mainly intervened to substitute a drug (n=132, 30.7%), adjust a dose (n=57, 13.3%), and clarify/complete information (n=48, 11.2%).
In 138 (32.1%) cases, the pharmacists contacted the prescriber whereas in 292 cases (67.9%), only the pharmacist was involved (alone n=59, with the patient n=222, with the caregiver n=11). A total of 243 PIs (56.5%) resulted in a change of the prescription. The implementation rate of PIs reached 88.6%.
Conclusion: During dispensing, pharmacists performed individualised PIs to solve or prevent drug-related problems concerning prescribed medicines. The high frequency of PIs following patient-reported problems highlight the importance of direct patient-pharmacist interaction when dispensing prescribed medicines.
Impact of findings on practice statements
• Pharmacists, as one of the last healthcare professionals interacting with patients prior to medication, add a relevant contribution in improving treatment outcomes by intervening in DRPs, particularly during the dispensing of prescribed medicines.
• Direct contact between pharmacists and patients during dispensing is essential to reveal the patient’s problems, concerns or dissatisfaction with prescribed medicines.
Key words
Pharmaceutical intervention; drug-related problem; community pharmacy practice; pharmaceutical care; classification system
PhD Thesis Karen Maes 100 Introduction
During the dispensing of prescribed medicines, community pharmacists frequently encounter technical and clinical issues resulting in a pharmaceutical intervention (PI). A PI is defined as a recommendation initiated by a pharmacist in response to a drug-related problem (DRP) in an individual patient occurring in any phase of the medication process [81]. In a medicines optimisation approach, the ultimate goal of pharmacists is to improve treatment outcomes. This is achieved by the exploring the patients’ experience, to choosing evidence based medicines and ensuring that the overall therapy is as safe as possible [111]. The pharmacist’s professional knowledge is essential to perform PIs aimed to improve pharmacotherapy and facilitate the collaboration with the patient and/or with other healthcare professionals [112]. The PI documentation could highlight the pharmacists’ activities that include proactively identifying, solving, and preventing DRPs during dispensing in community pharmacies [113, 114].
In prior research, we identified the need for a classification system for community pharmacies focusing on PIs. We subsequently developed and validated the Pharmacists’ Documentation of Interventions in Seamless Care (PharmDISC) system [85]. While the frequency and nature of DRPs detected in pharmacy practice have been exhaustively described [6], little is known on how community pharmacists handle these DRPs and how they intervene for patient-reported problems. Therefore, we performed a subanalysis with data from the PharmDISC validation study [85]; the documented PIs from that study allowed reliable and consistent analyses.
Aim of the study
The aim of this study was to describe PIs performed by community pharmacists during the dispensing of prescribed medicines and to investigate their response to patient-reported problems.
Ethical approval
This study was approved by the ethics committee of the Northwest and Central Switzerland (EKNZ:2014-102).
PhD Thesis Karen Maes 101 Method
A prospective observational study was conducted in Swiss community pharmacies. The study design has been described previously [85]. Each pharmacist consecutively collected 30 prescriptions requiring a PI on five selected days within five weeks in March and April 2015. The PIs were classified with the PharmDISC system [85], allowing information to be recorded with respect to the problem, type of problem, cause, intervention, persons involved, and outcome. In addition to the PharmDISC documentation (PI classification form), a short description, an anonymised prescription copy, and a three-month medication history were collected. All documentation was checked for consistency and plausibility for each PI. A descriptive manual and an online training were available for the participants [85]. The data were analysed using IBM SPSS Statistics for Windows, Version 22 (Armonk, NY:IBM Corp).
Results
Twenty-one (11 German-speaking and 10 French-speaking) pharmacists participated in the study. Of the 519 PIs documented with the PharmDISC system, 430 (82.9%) were completely classified in all categories. Eighty-nine PI classification forms did not fulfil all requirements for a complete classification and were therefore excluded from the analysis.
The patients for which a PI was documented were mostly female (n=233, 63.8%) regular customers (n=269, 81.1%) with a mean age of 55.9±23.5 years. The number of medicines per prescription ranged from 1 to 21 (mean 3.4±3.3). The 430 eligible PIs originated from 365 prescriptions (mean 1.2±0.48 PIs per prescription, range 1-4). Of these, 313 (85.8%) PIs were ambulatory, 45 (12.3%) based on a hospital discharge and 7 (1.9%) unknown.
The problems triggering PIs comprised treatment effectiveness (n=172, 40.0%), patient-reported problems (n=99, 23.0%), safety of treatment (n=98, 22.8%), treatment cost (n=53, 12.3%) and untreated indication (n=8, 1.9%). The cause of the PI was clinical for 242 PIs (56.3%) and technical for 188 PIs (43.7%). The pharmacists mainly intervened to substitute a drug (n=132, 30.7%), adjust a dose (n=57, 13.3%), and clarify/complete information (n=48, 11.2%) [Table 1].
Pharmacist-prescriber interaction was necessary in 138 (32.1%) cases, whereas the pharmacist alone was involved in 292 (67.9%) of PIs (alone n=59, with the patient n=222, with the caregiver n=11).
Overall, 243 PIs (56.5%) resulted in a change of the prescription. PIs were in 88.6% cases approved by the involved person and consequently implemented.
The number of medicines per prescription increased with the age (correlation r=0.233, p<0.001) and also with the number of PIs per prescription (r=0.236, p<0.001).
PhD Thesis Karen Maes 102
Table 1 Most frequent pharmaceutical interventions (n=430) on prescribed medicines in community pharmacies and their clinical or technical cause
Intervention n (%) Cause n (%) Problem n (%) Outcome n (%) Example
Patient preferred to take ibuprofen tablets instead of pellets.
Pharmacist substituted the dosage form.
Concerns about
A patient with generalised itching did not tolerate the newly prescribed dimetindene gel, the pharmacist proposed dimetindene drops.
The pharmacist detected a lower prescribed dose of lamotrigine than in prior prescription. The physician readapted the dose based on pharmacist’s recommendation.
Overdose 10
(21.3)
Safety of treatment 8 (80.0)
Accepted and implemented
7 (87.5)
Dextromethorphan dose was too high (12.5mg, 2-3 times/day) for an 18-month child. The pharmacist reduced the dose (6.25mg) to twice daily in the morning and the evening.
In-depth counselling
Patient supposed that acetaminophen causes his stomach trouble and wanted acetylsalicylic acid instead. The pharmacist clarified the confusion.
The patient agreed to switch the original product to generic escitalopram to safe costs.
Drug is currently undeliverable and not in stock at the wholesaler, but the pharmacist proposed an alternative.
Patient
The pharmacy does not have the prescribed drug in stock, but the pharmacist proposed an alternative dosage form.
Optimisation of
Correct timing of magnesium administration was not specified.
Due to drug-drug interaction, magnesium should be taken at lunch time, and the levothyroxine 30 minutes before breakfast.
Clarification/
The dose of the combination product valsartan +
hydrochlorothiazide was not specified on the prescription. The pharmacist clarified the correct dose with the prescriber.
PhD Thesis Karen Maes 103 Patient-reported problems
Patient-reported problems resulted in a PI in 99 cases (23.0%). Of these, 76 PIs had a clinical cause (Fig.
1) while 23 PIs had a technical cause. In 15 (15.2%) cases, the contact with the prescriber was necessary whereas 61 (84.8%) of PIs only involved the pharmacist (alone n=15, with the patient n=68, with the caregiver n=1). The PIs resulted in 66 cases (66.7%) to a change of the prescription, and of these, 52 cases (78.8%) were solved without the prescriber.
Fig. 1 Patient-reported problems with clinical causes and corresponding pharmaceutical interventions (n=76).
The size of the circle represents its frequency.
PhD Thesis Karen Maes 104 Discussion
This subanalysis demonstrated that community pharmacists applied a medicines optimisation approach for a broad range of PIs which was facilitate by direct patient interaction. The PIs were mostly accepted by the involved person and implemented in practice. Individual assessment of each PI, the pharmacist’s professional expertise, and the collaboration between the patient, caregiver or physician were needed to fully address the patients’ needs. This ensured a safe and appropriate use of medicines - all while controlling treatment costs.
Almost a quarter of the PIs were related to patients who reported problems with their prescribed medicines at the time of dispensing. It is known that after the prescription is handed over by the prescriber, problems for the patients may still remain. The prescriber possibly provides insufficient information that does not meet the patient’s needs. A Canadian study has previously revealed the discrepancies between the patient’s need for information on prescribed medicines and the information provided by pharmacists and physicians [115]. Direct contact between the healthcare professional and the patient is essential to detect these problems. By addressing these problems, adherence to medical treatment and consequently patient outcomes could be improved. Indeed, Horne et al reported that the patient’s beliefs and concerns are related to adherence, meaning that lower concerns correlated with higher adherence [116].
Another possible reason for remaining patient-related problems is that some concerns regarding therapy or the need for supplementary information may arise at a time after the consultation with the prescriber has taken place. The same Canadian study revealed that patients found it more convenient to receive information and counselling from the pharmacists rather than from the physician. This is likely a consequence of easy accessibility of the pharmacists and the challenge to contact the physician who often has time constraints [115]. Our findings confirm that patient-reported problems with prescribed medicines can frequently be addressed by community pharmacists. As one of the last healthcare professionals before patients take their medicines, pharmacists provide a relevant contribution in improving treatment outcomes by intervening in DRPs during the dispensing of prescribed medicines.
As this study collected data in two regions of Switzerland with different languages and cultures, the results provide a robust assessment that can likely be transferred to other regions. The main limitation was the inclusion of highly motivated and qualified pharmacists who participated in the study. We were not able to ensure the consecutive collection of prescriptions, which might have caused a selection bias. This would explain the high frequency of PIs compared to another observational study
PhD Thesis Karen Maes 105 that was conducted in Swiss community pharmacies which recorded all 38’663 patient visits with prescriptions during four weeks, revealing mean intervention rates of 1.90% related to 736 technical and of 0.77% related to 257 clinical DRPs [94].
Conclusion
By intervening during the dispensing of prescribed medicines, community pharmacists contribute to the safe, appropriate and cost-effective use of drugs. They have the opportunity to support the patient to make the best use of prescribed medicines by performing individualised PIs. The high number of PIs following patient-reported problems highlights the importance of a direct patient-pharmacist contact when dispensing prescribed medicines.
Acknowledgements
The authors thank the participating community pharmacists who contributed to our findings, and Helene Studer and Jasmine Ruppanner for their help in the data analysis. We thank Dr. Roland Preston for proofreading.
Funding None.
Conflict of interest None.
PhD Thesis Karen Maes 106