Pharmacist-led medication reconciliation and medication review practices at care transitions in primary care

The daily role of pharmacists has changed from that of a medication vendor and producer of extemporaneous formulations to providing a more patient- and care-focused practice through the introduction of pharmaceutical services. During this time, numerous pharmacist-led services have been introduced worldwide and the community pharmacists in Europe perform a variety of pharmacy services. However, the level of implementation and remuneration of pharmacist-led cognitive services in primary care across Europe is lacking.
Each person takes medication, at some point in their lifetime, for the prevention or treatment of a disease and can, therefore, be affected by drug-related problems (DRPs). The inclusion of multiple health care professionals in the care of patients taking medications is a risk for the development of medication errors and the continuity of patient care. The performance of medication reconciliation and medication reviews is an important intervention to prevent medication errors and improve various health outcomes, by enabling the identification and resolution of DRPs and medication discrepancies. Medication discrepancies can also arise in the outpatient setting at transitions between care homes, community pharmacies, primary care physicians, medical specialists, or even without any transitions if the patient takes the medication differently than prescribed. As the performance of medication reconciliation is laborious and resource-intensive, information technology (ranging from simple emails to specialized electronic tools) is used to facilitate medication reconciliation processes. To date, Swiss community pharmacies do not have medication reconciliation tools specifically developed to help community pharmacists to compare the best-possible medication history to admission, transfer, discharge orders and to resolve medication discrepancies. In addition, electronic health records (EHRs) are used to support medication reconciliation processes. The worldwide implementation of such EHRs has increased in recent years. Theoretical advantages and risks linked to EHRs are mainly related to the management and storage functionalities of electronic health data (e.g. the ability to access, search, manipulate, transport, share, and preserve electronic data).
The goals of this thesis are to assess different aspects of pharmacist-led cognitive services in Europe with a focus on medication review procedures, to evaluate medication discrepancies and DRPs identified by systematic medication reconciliation in community pharmacies, and to develop an electronic medication reconciliation tool for community pharmacies. These goals were approached with four main projects:
Project A aimed to assess the implementation of 21 different pharmacist-led cognitive services performed in primary care across Europe and the associated remuneration models. The pharmacist-led cognitive services with the widest dissemination were the provision of medicines’ information (94.1%), generic substitution (85.3%), provision of emergency oral contraception (70.6%) and point-of-care testing (67.7%). [A-1] Furthermore, Project A aimed to describe the characterization of the different types of medication review services and projects available, the level of implementation and remuneration in community pharmacies. Over 50% of the investigated countries provided at least one type of medication review as an implemented service or project. There was great heterogeneity in the availability, level of implementation and remuneration of investigated pharmacist-led cognitive services across Europe. [A-2]
In Project B, we investigated the identification, characterization, and categorization of medication discrepancies occurring in adult community pharmacy customers with long-term polypharmacy use and to assess their potential clinical and economic impact. Overall, 116 patients (mean age 74 ± 10.3 years) with an average of 10.2 (± 4.2) medications were analysed and 317 discrepancies were identified. The most frequent discrepancy type was related to “strength and/or frequency and/or number of units of dosage form and/or the total daily dose”. Although the majority of discrepancies were rated as inconsequential (55.2%) on patients’ health conditions, the remainder had a potential moderate (43.2%) or severe impact (1.6%). Focusing on the economic impact, in 49.5% of the discrepancies, patients’ medication cost less than the prescribed medication. [B-1] In addition, we assessed the patients’ awareness of generic medications in their therapy, perception of specific aspects, and attitudes towards generic medication and substitution. More than a quarter (27.9%) of patients (n=136) were not aware of using at least one generic medication. Overall, 26.4% of the prescribed medications were eligible for medication substitution but were not substituted. The cost was the most commonly reported advantage of generic medications (n = 120) whereas the taste of generic medication was most frequently reported as a disadvantage (n = 42) [B-2] Third, we evaluated the medication discrepancies identified by pharmacy students in discharged patients in community pharmacies in Switzerland. A total of 51 patients were included and the patients had an average of 13.5 ± 5.2 prescribed medications prior to hospital admission and 11.0 ± 4.5 medications on the discharge prescription. Overall, the pharmacy students identified 557 medication discrepancies and 98.0% of the patients had at least one medication omission or commission. [B-3]
Project C assessed whether DRPs identified on discharge prescriptions in a hospital’s community pharmacy (with full access to the hospital’s electronic health records) would be detectable in a community pharmacy by simple medication reviews based on the patient’s medication history only, or if intermediate or advanced medication review with additional clinical and/or patient-specific information would be needed. And we also assessed whether the resolution of the DRPs that were deemed detectable by a simple medication review would require a consultation with the prescriber. In total, 6087 prescriptions were filled in the hospital community pharmacy by patients from the internal medicine unit. Overall, 1876 DRPs were identified among 1352 different prescriptions, 23% were caused by reconciliation problems at hospital admission and 73% by prescribing problems during the hospital stay or at discharge. The retrospective assessment showed that community pharmacists conducting simple medication reviews (based on discharge prescriptions and medication history only) would be able to detect 1115, whereas for the detection of the remaining DRPs, additional clinical and/or patient-specific information is needed. In 944 DRPs detectable by simple medication reviews, the pharmacist would need to consult the prescriber for their resolution. [C-1]
Project D aimed to examine the acceptance and satisfaction of patients, community pharmacists, physicians and caregivers with the electronic medication plan and to investigat the number of discrepancies between the discharge prescription and the dispensed medicines in the community pharmacy. Additionally, we analysed the number and type of interventions performed by the community pharmacists filling the hospital discharge prescription. During the pretest of the electronic medication list and the eHealth platform, the research team identified multiple problems and bugs by entering different fictional persons to the eHealth platform and by testing the electronic medication list application. The identified patient safety and usability problems and bugs were listed and transmitted to the provider for further improvement. Between July and November 2017, iterative rounds were needed to improve the eHealth platform and, in particular, the application for the electronic medication list. Afterwards, the research team decided to perform a pilot study recruiting patients during one month to assess the feasibility of the study design and to optimize the study processes. Unfortunately, the project was discontinued after one year. [D-1]
In addition, we aimed to develop an algorithm that enables the identification of medication discrepancies and medication duplications in community pharmacies and to assess the feasibility of the electronic medication reconciliation tool by adding different case studies of three Anatomical Therapeutic Chemical (ATC) subgroups C01, C03 and C10 followed by a second feasibility assessment evaluating different case studies including all ATC groups. [D-2] Furthermore, we aimed to examine the efficiency, effectiveness and satisfaction of the electronic medication reconciliation tool. Initially, a set of requirements was compiled through a pragmatic literature search and an algorithm for the development of an electronic medication reconciliation tool was designed, based on different national and international coding systems. The feasibility testing and piloting of the first version of the electronic medication reconciliation tool showed that in 76.5% of the case studies the output of the electronic tool was confirmed by two pharmacists of the research team. The subsequent feasibility testing and evaluation of the electronic medication reconciliation tool will be performed beyond this thesis. [D-2]
Conclusions
Project A:
- There was great heterogeneity in the availability, level of implementation and remuneration of investigated pharmacist-led cognitive services across Europe, with some countries standing out as early adopters, leading the way and serving as examples for other countries.
- The research team was aware that the definition of specific terms used in surveys across language and national borders is pivotal because the responders’ personal perceptions (influenced by the language, culture, and daily practice) affect the responses and lead to insufficient comparability of responses across different regions and countries.
- The development of transnational surveys by an international team and piloting with multiple experts from different countries help to identify deficiencies in the survey regarding the definition and perception of central terms used in the survey. The inclusion of multiple individuals per country and the consensus-seeking process in a survey assessing country-specific information is a suitable method to ensure credible data.
Project B:
- Numerous medication discrepancies were identified by the performance of systematic medication reconciliation in patients with polypharmacy in community pharmacies in Switzerland. Community pharmacists should be encouraged to reconcile patients’ medication systematically at each encounter to identify and resolve medication discrepancies impeding optimal medication therapy.
- Generic substitution is responsible for numerous medication discrepancies at care transitions. Health care professionals should be aware of these discrepancies and counter patients’ lack of knowledge about their generic medications to avoid medication errors. Moreover, most of the aspects differing between brand name and generic medications were not relevant for the majority of the study patients. Therefore, health care professionals should not hesitate to recommend generic medication and therefore strengthen efforts in achieving higher rates of generic substitution through patient counselling and shared decision making to decrease general health care costs.
Project C:
- Systematic medication reconciliation and medication reviews of the hospital medication and patients’ home medication are indispensable prior to hospital discharge to identify and resolve potential DRPs, to ensure an accurate medication prescription and to continue an optimal medication therapy after hospital discharge.
- The documentation of the intentional medication changes in the discharge prescription and patient medication list might help patients and all subsequent health care providers to identify and implement the intended medication changes after hospital discharge. Furthermore, this documentation might reduce the need for prescriber consultations by subsequent health care professionals, which saves the resources and time of all involved actors in the health care sector.
- The ability to identify DRPs is strongly influenced by the extent of different information sources available to pharmacists at hospital discharge. The vast majority of community pharmacists in Switzerland have no access to clinical patient information (e.g. diagnosis, laboratory values) and discharge summaries. Therefore, community pharmacists might not identify all DRPs in the patient’s medication after hospital discharge. Moreover, community pharmacists’ lack of clinical information limits plausibility checks of medication changes and medication appropriateness after discharge and triggers further consultations with the prescriber for clarification.
- The performance of simple medication reviews enable detection of approximately 60%, a majority of these DRPs would require contact with the prescriber for resolution. This is facilitated when the medication reconciliation and review activities take place in close collaboration with or at least in the vicinity of the prescriber, which might also have a positive effect on the communication and acceptance of the pharmacist's recommendations.
Project D:
- A participatory action research approach with the integration of end-users with different working backgrounds (e.g. patients, physicians, pharmacists, nurses, physiotherapists) in all development phases might prevent problems with electronic health records and novel electronic medication applications. Furthermore, electronic health records need comprehensive evaluation prior to their introduction in the Swiss health care system to identify and resolve the safety and usability issues of this novel application.
- The development of an electronic tool supporting medication reconciliation needs close cooperation between the different actors of the development team and multiple interim evaluations to identify and subsequently overcome the safety and usability issues of the novel tool.