Implementation of pharmacist-led medication reviews in general practice

Abstract

Medication review conducted collaboratively by pharma-cists and general medical practitioners (GPs) is a widelyresearched strategy to optimise medication use [1–3].Home Medicines Review (HMR) is an Australian gov-ernment funded collaborative medication review servicefor people living independently in the community. Thisservice has traditionally involved a GP referring a patientto their preferred community pharmacy, which in turnarranges a pharmacist to conduct the review. In October2011, an additional referral pathway was introduced.Rather than referring to a community pharmacy, GPs maynow refer directly to an HMR accredited pharmacist. Inthis issue, Freeman et al. [4] describe an innovative prac-tice model, consistent with this new referral pathway, inwhich an accredited ‘practice-pharmacist’ works in a GPmedical practice.Despite the exploratory nature of the study, a number ofbenefits were apparent. Firstly, the ‘practice-pharmacist’completed over 300 HMRs in a year period compared to anaverage of approximately 10 HMRs per year under thealternative ‘external-pharmacist’ model. Increased uptakeand timeliness of HMRs is likely to have public healthbenefits [5, 6]. A recent study reported just 5.5 % ofpatients at high risk of ADEs received an HMR [5]. Sec-ondly, while the ‘practice-pharmacist’ identified fewerdrug-related problems per patient than the ‘external-phar-macist’ (3.6 vs. 5.4), a higher percentage of recommen-dations made by the ‘practice-pharmacist’ was implementedby the referring GP (71 vs. 53 %). As suggested by theauthors, access to patients’ medical records while under-taking the review may have ensured recommendationswere more relevant to clinical care. Greater rapportresulting from integration of the ‘practice-pharmacist’ intothe GP team may have also contributed to higher rates ofrecommendation implementation. Thirdly, the modeldescribed by Freeman et al. provided ample opportunitiesfor face-to-face post HMR discussion between the phar-macist and GP. Post HMR case conferences were includedin much of the original Australian research on whichimplementation of the HMR service was based [7, 8].An issue not explored by Freeman et al. was the reasonsfor non-acceptance of the pharmacists’ recommendations.Reasons for non-acceptance of the pharmacists’ recom-mendations may have included patients’ preference not toalter their medication regimen, GPs having greaterknowledge of patients’ therapeutic goals, or psychologicalreactance among GPs [9]. A further issue not explored waswhether the nature of the findings and recommendationsmade by the ‘practice-pharmacist’ changed over time.Recommendations for one patient might have beenextrapolated to others. Working in the practice may havemeant that the pharmacist’s HMR recommendationsbecame more aligned with the needs and expectations ofGPs. The pharmacist may have been also able to identifyand act upon practice-level prescribing issues.In the model described by Freeman et al. the patient wasable to choose the location of the HMR, either in theirhome or the GP medical practice. Interestingly, the locationof the HMR had little impact on the types of HMR rec-ommendations. The home visit is widely considered a keycomponent of the review process. It provides an opportu-nity to check medication storage, remove expired medi-cation, and to compile a complete medication list (e.g.