Clinical pharmacy services and evaluation of medicines use : the case of the swiss polymedication check

Abstract

This thesis aimed at giving a general overview over clinical pharmacy services already performed in the Swiss hospital setting and discussing the strengths and limitations of pharmacist-led medication reviews in primary care by evaluating the Swiss Polymedication Check. In addition, specific opportunities for further clarification through pharmacist-led interventions are highlighted in order to select patients at highest needs for future services. Project A aimed at presenting an overview of existing clinical pharmacy services in the hospital care setting. We performed the first comprehensive survey of clinical pharmacy practice in Switzerland. Our data show considerable regional differences concerning the extent of implementation and pattern of clinical pharmacy services, which points out to the existing crucial gap in seamless care activities. In order to approach the topic of drug-related problems in patient care from a solution-oriented perspective, the potential of pharmacist-led medication reviews in various settings became a focus of the Pharmaceutical Care Network Europe (PCNE) and was extensively discussed at several meetings and workshops. Findings of project A: - In Switzerland, regional differences in the extent of implementation and pattern of clinical pharmacy services are observed, highlighting a crucial gap in seamless care activities. - The Pharmaceutical Care Network Europe agreed to a definition for medication reviews and encourages pharmacists to offer pharmaceutical care regardless of the setting. - Medication reviews offer an excellent opportunity to detect drug-related problems and initiate pharmaceutical care as a contribution within patient care. - The impact of medication reviews is directly linked to the subsequently provided intervention to solve a detected drug-related problem and to the acceptance rate of this recommendation by the patient and/or the prescriber. Project B extensively studied the Polymedication Check (PMC), a cognitive and directly remunerated pharmacist-led medication review service in Switzerland. For the first time in the Swiss health care system, a new nationally implemented cognitive service underwent an in-depth evaluation process in daily life setting. Two years after the launch of the service, the Pharmaceutical Care Research Group of the University of Basel initiated an evaluation project (evalPMC) aiming at investigating the impact of the service on medicines use and humanistic outcomes. Findings of project B: - The Polymedication Check underwent an in-depth evaluation process in a prospective randomised controlled trial performed in the German and French part of Switzerland. - No significant impact of the pharmacist-led intervention was shown on objective adherence, while subjective adherence was improved shortly after the intervention. - In addition, patients’ knowledge on medicines was improved by the intervention and patient’s acceptance of the service was high. - The evalPMC project highlighted the need for a re-engineering of the service in order to focus on patients at highest risks for drug-related problems and approach them with tailored interventions. - Moreover, a follow-up meeting may become an important element in a future service, following the concept of a continuous pharmaceutical care process. - Pharmacists were highly motivated to perform PMCs once they had overcome the barrier of ‘the first is the worst’. Project C based on the main conclusion of Project B (need for more tailored interventions to targeted patients) and investigated the potential of the community pharmacy setting to offer the pharmacist’s skills purposefully to patients with individual needs. Patient-centred counseling may become more sensitised for specific and underestimated drug-related problems, i.e. swallowing difficulties with medication intake. We therefore developed an in-depth patient self-report questionnaire, which was used in a cohort of patients with systemic sclerosis (SSc) from the European Centre for the Rehabilitation of Scleroderma Rheinfelden, Switzerland. Findings of project C: - Existing campaigns performed by community pharmacies offer a wide range for future services aiming at improving therapy efficacy and patient safety. - Unreached biomarkers despite drug therapy as well as swallowing difficulties with medication intake need further clarification by a health professional to rule out inadequate coping strategies or non-adherence. - Patient self-reports may guide health professionals in the future when providing tailored counseling, choosing therapy options, or optimising a patient’s medication profile. In conclusion, this thesis showed an increase of the involvement of clinical pharmacists in patient care in Switzerland. Regardless of the setting, the traditional role of pharmacists is currently expanding to a respected contributor and key partner for interprofessional collaboration in patient care. Pharmacists’ contributions to patient care are no longer limited to medicines supply only. Multiple opportunities for new services are opening up and their implementation is becoming of crucial importance to tackle the challenges posed by the demographic change and a lack of human and financial resources. In order to overcome internal and external barriers, pharmacists need to assume more responsibility and train their skills in clinical pharmacy practice and interprofessional collaboration. The patients proved to be highly motivated to follow pharmaceutical care models, which is a very promising finding for the development of future services.