Statement of contribution
T ABLE 16 S OURCES AND TYPES OF DATA COLLECTED FOR EACH HMR
DATA SOURCE DATA COLLECTED
HMR referral
Reason for referral
Patient demographics (age, sex, medical conditions) Pathology/ laboratory data
HMR report
Medication profile DRPs identified Recommendations
Outcomes GP acceptance or rejection of pharmacists’ recommendations
All patient diagnoses and medical conditions were classified using the International Classification of Primary Care Version 2 PLUS (ICPC2-PLUS, Family Medicine Research Centre, University of Sydney).202 Patient medications were recorded using Anatomic Therapeutic Chemical (ATC, World Health Organisation) coding.
All data relating to the HMRs analysed was submitted by the accredited pharmacist who performed the HMR. Accredited pharmacists were asked to submit details pertaining to HMRs that they performed between March and November of 2008. To reduce the possibility of selection bias, participating pharmacists were requested to submit details of sequentially the next five HMRs they performed after enrolling in the study. The pharmacist enrolment/ consent to participate form is shown in Appendix II.
It was envisaged that outcomes data would be readily available from the medication management plan formulated by the GP following the HMR. If no medication management plan was received, then the pharmacist was asked to contact the GP directly and obtain the relevant outcome data using a “Outcomes summary” form (Appendix III). It is noteworthy that the “Outcomes” in Table 16 only included the DRPs that required the GP to accept and implement the pharmacists’ recommendation/s to resolve. It was envisaged that many DRPs would have been resolved by the pharmacist without requiring the GP’s direct involvement. A limitation of this design is that, whilst the GP may have agreed with the pharmacist’s assessment and recommendation to resolve a DRP, the patient may not have agreed to the changes suggested. Hence, what actually happened may not have been captured using the “Outcomes summary” form.
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Page 83 Outcome data was not collected for every recommendation made by the pharmacist. Previous research suggested that the mean number of DRPs that would be identified in the VALMER study would be between two and five (Table 2). Anecdotal evidence from experienced accredited pharmacists indicated that the acceptance of recommendations made in HMRs diminishes as the number of recommendations increases. Additionally, it was considered that most pharmacists prioritise the DRPs identified in HMRs from most to least clinically relevant. Consequently, data regarding the outcomes of the first three recommendations made by the pharmacist in the HMR report was collected by the accredited pharmacist who performed the HMR. It was planned that these data would be used to provide an indication as to the outcomes of the recommendations made in the HMR report with the greatest potential to improve patient health and reduce health resource utilisation. The limitations resulting from this approach are discussed in detail in Section 7.3.1.2.To create awareness of the project and facilitate its promotion, the acronym VALMER (the Economic Value of Home Medicines Reviews) was used. Throughout this thesis, VALMER is used to describe the study that was undertaken to investigate the clinical and economic outcomes of HMRs. The results of the VALMER study are presented in chapters 5 and 6.
2.1.3.2 Inclusion and exclusion criteria
Any HMR undertaken in the data-collection phase of the study was eligible for inclusion. The only criteria for exclusion from the study were as follows:
HMR performed outside of the data collection phase (due to an increased risk of HMR selection by the submitting pharmacist);
incomplete or missing referral or HMR report data.
2.1.3.3 Pharmacist recruitment
Accredited pharmacists were recruited using advertisements in a variety of professional pharmacy-specific media. Advertisements were published in Australian Pharmacist, Australian Journal of Pharmacy and The Accredited Pharmacist magazines (an example may be found in Appendix IV), and a media release was distributed by the
Andrew Stafford BPharm(Hons) MPS AACPA
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Page 84 Pharmacy Guild of Australia (Appendix V). The project was also promoted at the three largest accredited pharmacist-specific continuing education events in 2008., which were: the accredited pharmacist forum at the Australian Professional Pharmacy Conference, Gold Coast, Queensland (27 March 2008);
the AACP Consultant Pharmacy Clinical Seminar, Adelaide (29 May-1 June 2008); and
the accredited pharmacist forum at the Pharmacy Australia Congress, Perth (24 October 2008).
The website www.valmer.com.au was also used to promote the study, and serve as a resource for participants to download the materials required for participation and newsletters containing project updates (Appendix VI).
2.2 Pharmacist characteristics
The pharmacists who participated in the VALMER study by submitting HMRs were characterised in two ways. They completed a survey that described their general demographics, and their clinical knowledge was assessed using their score for the AACP accreditation and reaccreditation examinations.
2.2.1 General demographics
The characteristics of the pharmacists who participated in the VALMER study were assessed with an online survey that was distributed in April 2009 (Appendix VII). The survey covered the following aspects of the pharmacists’ training and practice:
education history (undergraduate, postgraduate and professional development);
years of experience in different areas of pharmacy practice;
current employment status;
number of HMRs and RMMRs performed and years of experience performing MMRs;
Andrew Stafford BPharm(Hons) MPS AACPA
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Page 85 use of software when performing MMRs.2.2.2 Clinical performance
As discussed in Section 1.2.2.3 (page 24), all pharmacists must successfully complete a 50-question multiple-choice examination to initially achieve MMR accreditation with AACP. Once accredited, they must then pass this assessment every three years.129 The minimum pass score for the examination is 74% (37 correct responses out of 50). The AACP states that the assessment has been designed to assess “competence in clinical pharmacy, therapeutics, pharmaceutical care and medication review… <focussing on> knowledge of the principles of geriatric medicine, rational and safe pharmacotherapy in the elderly, and the appropriate use and interpretation of laboratory tests”.129
This examination was used to provide an indication of the clinical knowledge of the pharmacists who participated in the VALMER study. The AACP provided examination scores for every pharmacist who sat this examination between March 2007 and June 2009. This allowed a number of investigations to be made, including:
comparisons between the scores of the pharmacists who participated in the VALMER study with those of all pharmacists who undertook the assessment to investigate whether the VALMER pharmacists were representative of all AACP-accredited pharmacists in terms of clinical knowledge; and
whether the pharmacists’ clinical knowledge was related to the cost- effectiveness of their medication reviews.
2.3 Drug-related problems
The studies discussed in Chapter One of this thesis demonstrated that there is considerable uncertainty regarding the outcomes resulting from the identification and resolution or prevention of DRPs in MMRs. However, it seems that the type of DRPs identified in medication reviews is somewhat related to their cost-effectiveness. Furthermore, several authors have asserted that any assessment of medication reviews must include documentation of the types of DRPs that were addressed in the reviews.151, 166
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Page 86 In consideration of this, every DRP documented in the HMR reports was classified using a version of a classification system that had been developed specifically for use in HMRs, called the DOCUMENT classification system.203 This was a derivative of a system that has been used and refined in three studies spanning 10 years of research into DRP detection and resolution by Australian community pharmacists.50 Using this hierarchal DRP classification system, the following aspects of each DRP were recorded: the characteristics of the DRP (type and subtype, drugs and medical conditions involved); the recommendations made to resolve or prevent the DRP, and the outcomes of the recommendations. All classification was undertaken by the researcher rather than the reviewing pharmacist to ameliorate inter-rater inconsistencies, which are common in DRP classification.482.3.1 DRP characteristics
The DOCUMENT system is a two-tiered hierarchical classification that defines 38 subtypes of DRP, grouped into 8 DRP types (Table 17).
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Page 87TABLE 17-TYPE AND SUBTYPES OF DRPS DEFINED BY THE DOCUMENT