Home Medicines Review Research Articles

A pharmacist-led intervention for increasing the uptake of Home Medicines Review (HMR) among residents of retirement villages (PHARMER): protocol for a cluster randomised controlled trial

BackgroundThe majority of retirement village residents are at risk of medication misadventure. In a recent survey of retirement village residents in Victoria, two-thirds had at least one medication-related risk factor, and hence were eligible to receive a government-subsidised Home Medicines Review (HMR). However, only 6% of eligible residents had received a HMR in the previous 12 months. Reasons for the poor uptake of HMR, and interventions for improving HMR uptake, have been identified and developed with input from stakeholders. The trial will test the effect of Pharmacist-conducted HMR to Address the Risk of Medication-related Events in Retirement Villages (PHARMER) in improving the uptake of HMRs among retirement village residents.Methods/DesignThis is a multicentre prospective cluster randomised controlled trial. Ten retirement villages in Victoria, Australia will be recruited for this trial. Retirement villages will be selected in consultation with the Residents of Retirement Villages Victoria Inc. (RRVV), based on geographical locations (e.g. northeast or southwest), size and other factors. Residents from selected villages will be recruited with the help of RRVV Resident Liaison Officers using a range of strategies. Randomisation will be by geographical location to minimise contamination. Participating villages and residents will be allocated to either Pharmacist Intervention Group (PIG) or Usual Care Group (UCG). Each group will include five retirement villages and will have at least 77 residents in total. The intervention (PHARMER) comprises educating residents regarding HMR, and using a risk assessment checklist by residents to notify their General Practitioners of their medication risk. Uptake of HMR and medication adherence will be assessed in both PIG and UCG at three and six months using telephone interviews and questionnaires.DiscussionThis study is the first to develop and test an intervention to improve the uptake of HMR among Australian residents in retirement villages, with a view to decreasing medication risk. A multi-faceted interventional approach will be used as suggested by stakeholders. The trial is expected to be complete by late 2011 and results will be available in 2012.Trial RegistrationAustralian New Zealand Clinical Trials Registry (ACTRN12611000109909)

Medicine use of elderly Chinese and Vietnamese immigrants and attitudes to home medicines review

There is a paucity of research into the perceptions of elderly Australian ethnic minorities towards public health services related to quality use of medicines. Among the six fastest growing ethnic groups in Australia, the Mandarin-speaking Chinese and Vietnamese constitute the largest elderly populations with poor English skills. This paper investigates the relationships of elderly Chinese and Vietnamese migrants with medicines, general practitioners and pharmacists, and how these relationships influence their awareness and attitudes of the home medicines review (HMR) program. Two semi-structured focus groups were held with a total of 17 HMR-eligible patients who have never received a HMR, one with Chinese and one with Vietnamese respondents, each in the respective community language. Confusion about medications and an intention to have a HMR were pronounced among all participants although none of them had heard of the program before participating in the focus groups. Respondents reported difficulties locating a pharmacist who spoke their native language, which contributed to an increased unmet need for medicine information. The Chinese group additionally complained about a lack of support from their general practitioners in relation to their medicine concerns and was adamant that they would prefer to have a HMR without the involvement of their general practitioner. Our results indicate a distinct HMR need but not use among elderly Chinese and Vietnamese eligible patients with poor English skills. Home medicines review service use and perceived medication problems are likely to improve with an increasing availability of bilingual and culturally sensitive health care providers.

Improving the uptake of the Australian Home Medicines Review (AHMR) through patient segmentation

PurposeThe purpose of this paper is to investigate the problems patients and caregivers have with using medicines appropriately, their desire for assistance with managing medications and their self‐perceived need for the Australian Home Medicines Review (AHMR).Design/methodology/approachA qualitative research study was conducted with eight semi‐structured focus groups, including a total of 50 HMR‐eligible patients and caregivers. Participants who were purposively sampled represented older males, older females, younger chronically ill patients, patients from Chinese and Arabic backgrounds and the general HMR target group.FindingsAccording to the types of medicine problems encountered by participants, their level of medicine understanding and their desire for assistance with using medicines, four distinct patient segments are identified and explicated: the heedless patient, the aware patient, the scrupulous patient and the self‐sufficient patient.Practical implicationsThe uptake of the HMR service can be effectively increased by direct‐to‐consumer HMR promotion that is tailored to the behaviors, needs, and desires of eligible patients and caregivers. The proposed segmentation model of HMR‐eligible consumers addresses these differences and can be used to inform health policy makers regarding a more effective promotion of the HMR service.Originality/valueThis is the first study to investigate how the HMR‐uptake could be increased, from the perspective of eligible patients and their caregivers.

General practitioner–pharmacist interactions in professional pharmacy services

Australian community pharmacies offer a range of professional pharmacy services (PPS) which include Home Medicines Review (HMR) and the Diabetes Medication Assistance Service (DMAS). The extent of interaction and collaboration between general practitioners (GPs) and pharmacists in the context of these services is unknown. Therefore, the aim of this study was to investigate (1) the nature and extent of interactions between GPs and community pharmacists and; (2) the factors that influence these interactions in the context of PPS. Individual semi-structured face-to-face and telephone interviews were conducted with a purposive sample of 15 GPs and 15 pharmacists in rural and metropolitan areas of New South Wales, Australia. The results indicated that involvement in PPS resulted in a perceived increase in the level of interactions between the pharmacist and GP. Factors found which may influence collaborative behaviour in PPS include interactional, practitioner and environmental determinants. These factors are in line with what has previously been reported however, facilitators of collaboration in the primary care, PPS context included additional environmental factors such as the presence of rules and protocols, interprofessional continuing education and the availability of adequate remuneration. Attention to these environmental factors as well as the more established interactional and practitioner determinants will improve collaboration in PPS.

Exploring Medication Risk among Older Residents in Supported Residential Services: A Cross‐Sectional Study

ABSTRACTBackgroundOlder residents in supported residential services (SRS) are often on multiple medications and may be at risk of medication misadventure. Their medication risk and uptake of medication reviews by pharmacists has not been investigated.AimTo investigate medication use, risk factors for medication misadventure and uptake of home medicines review (HMR) among older residents in SRS.MethodA pre‐piloted postal survey was distributed to 361 residents from 14 SRS in Victoria. The questionnaire included validated items on medication risk, medication use, health information and uptake of HMR. The questionnaire was completed by residents, SRS care staff or family members.ResultsOf the 77 respondents (21% response rate) aged 53 to 98 years, 73 (95%, 95%CI 90–100) reported taking prescribed medications. Risk factors for medication‐related problems were present in 56 respondents (73%; 95%CI 63–83) and included: ≥ 5 regular medications (n = 41; 53%; 95%CI 42–64), ≥ 3 comorbidities (n = 31; 40%; 95%CI 29–51), medications with low therapeutic index (n = 15; 20%; 95%CI 11–28), recent hospitalisations (n = 12; 16%; 95%CI 7.5–24), recent changes to medication regimens (n = 10; 13%; 95%CI 5.5–21) and ≥ 12 tablets/capsules a day (n = 9; 12%; 95%CI 4.5–19). Of these at‐risk respondents, only 3 (5.4%; 95%CI 0.4–11) reported receiving an HMR in the previous 12 months.ConclusionHigh prevalence of medication use and medication‐related risk factors, but low awareness and uptake of HMR were identified among SRS residents.

Consumer perspectives of the Australian Home Medicines Review Program: Benefits and barriers

Background The Australian Home Medicines Review (HMR) is a free consumer service to assist individuals living at home to maximize the benefits of their medicine regimen and prevent medication-related problems. It consists of a pharmacist reviewing a person’s medicines and collaborating with the general practitioner to optimize the individual’s medicine management. The uptake of this service has remained below the projected use, although the program has shown to successfully identify medication-related problems and improve drug knowledge and adherence of the patient. Objectives This study investigates the perceived benefits and barriers of the patients regarding the HMR service who have used the service and who are eligible for it but have never used it. Methods Consumer perceptions were drawn from 14 semistructured focus groups, with patients and carers belonging to the general HMR target population and consumer segments that have been postulated to be underrepresented with regard to this service. Results The major benefits reported were acquisition of medicine information, reassurance, feeling valued and cared for, and willingness to advocate medication changes to the general practitioner. Perceived barriers were concerns regarding upsetting the general practitioner, pride and independence, confidence issues with an unknown pharmacist, privacy and safety concerns regarding the home visit, and lack of information about the program. Participants agreed that the potential benefits of the service outweighed its potential barriers. Conclusions It is expected that direct-to-consumer promotion of HMRs would increase the uptake of this valuable service. It would be necessary to ensure that the process and benefits of the service are communicated clearly and sensitively to eligible patients and their carers to obviate common consumer misconceptions and/or barriers regarding the HMR service. Furthermore, any direct-to-consumer promotion of the service must enable patient/carer self-identification of eligibility.

A Sociocognitive Approach to Service Quality and Adherence Amongst Elderly Patients: A Pilot Study

This article examines the relationship between patients' perceptions of emotional intelligence (EI), health competence, service quality, and adherence behavior in the Home Medicines Review (HMR) setting. Participants were purposively recruited from different urban and regional areas in Australia and qualitative data were obtained from in-depth interviews with 20 HMR patients. Service quality is conceptualized from a sociocognitive perspective by incorporating psycho-socio factors such as EI and health competence as moderators to overall service quality and adherence. The findings suggest that EI and health competence influence patient perceptions of service quality and nonadherence at multiple levels of abstraction. Implications are that staff training and development programs that incorporate EI could improve service delivery which could increase patient perceptions of service quality and adherence. Designing intervention initiatives aimed at increasing patient awareness and education of their health conditions could also improve service quality perceptions and adherence behavior.

Feasibility and Timeliness of Alternatives to Post‐Discharge Home Medicines Reviews for High‐Risk Patients

ABSTRACTBackgroundThe period 7 to 10 days following hospital discharge is associated with a significant risk of medication misadventure, especially in high‐risk patients.AimTo investigate whether post‐discharge hospital‐initiated medication review (HIMR) pathways are more timely than the post‐discharge home medicines review (HMR) pathway.MethodAn implementation study conducted over 9 months in 2008/2009 of patients from 3 South Australian hospitals. A risk stratification instrument was used to identify patients at “high” risk of medication misadventure. Feasibility was assessed and time to conduct the post‐discharge medication reviews was determined for the HMR and HIMR pathways.ResultsOf the 97 consenting patients, 92 were stratified as “high” risk. HIMR were organised for 59 patients − 52 patients completed the HIMR process. Of the 22 HMRs organised via the patient's general practitioner, 18 patients completed the HMR process. The time from request to conducting the HIMR and HMR were statistically significantly different – HIMR and HMR took 6.5 ± 4.7 days and 11 ± 7.4 days, respectively (p = 0.02).ConclusionThis study has demonstrated the feasability of alternative pathways to post‐discharge medication reviews. The HIMRs were conducted sooner than HMRs organised via existing community processes. If post‐discharge medication reviews are organised via the HIMR pathway, there is potential to reduce medication misadventure in high risk patients in a more timely manner than when post‐discharge HMRs are organised.

Clinical Outcomes of a Collaborative, Home-Based Postdischarge Warfarin Management Service

Warfarin remains a high-risk drug for adverse events, especially following discharge from the hospital. New approaches are needed to minimize the potential for adverse outcomes during this period. To evaluate the clinical outcomes of a collaborative, home-based postdischarge warfarin management service adapted from the Australian Home Medicines Review (HMR) program. In a prospective, nonrandomized controlled cohort study, patients discharged from the hospital and newly initiated on or continuing warfarin therapy received either usual care (UC) or a postdischarge service (PDS) of 2 or 3 home visits by a trained, HMR-accredited pharmacist in their first 8 to 10 days postdischarge. The PDS involved point-of-care international normalized ratio (INR) monitoring, warfarin education, and an HMR, in collaboration with the patient's general practitioner and community pharmacist. The primary outcome measure was the combined incidence of major and minor hemorrhagic events in the 90 days postdischarge. Secondary outcome measures included the incidences of thrombotic events, combined hemorrhagic and thombotic events, unplanned and warfarin-related hospital readmissions, death, INR control, and persistence with therapy at 8 and 90 days postdischarge. The PDS (n=129) was associated with statistically significantly decreased rates of combined major and minor hemorrhagic events to day 90 (5.3% vs 14.7%; p=0.03) and day 8 (0.9% vs 7.2%; p=0.01) compared with UC (n=139). The rate of combined hemorrhagic and thrombotic events to day 90 also decreased (6.4% vs 19.0%; p=0.008) and persistence with warfarin therapy improved (95.4% vs 83.6%; p=0.004). No significant differences in readmission and death rates or INR control were demonstrated. This study demonstrated the ability of appropriately trained accredited pharmacists working within the Australian HMR framework to reduce adverse events and improve persistence in patients taking warfarin following hospital discharge. Widespread implementation of such a service has the potential to enhance medication safety along the continuum of care.

Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans

Unintended bleeds are a common complication of warfarin therapy. We aimed to determine the impact of general practitioner-pharmacist collaborative medication reviews in the practice setting on hospitalization-associated bleeds in patients on warfarin. We undertook a retrospective cohort study using administrative claims data for the ambulatory veteran and war widow population, Australia. Participants were veterans, war widows and their dependents aged 65 years and over dispensed warfarin. The exposed groups were those exposed to a general practitioner (GP)-pharmacist collaborative home medication review. The service includes GP referral, a home visit by an accredited pharmacist to identify medication-related problems, a pharmacist report with follow-up undertaken by the GP. The outcome measure was time to next hospitalization for bleeding. There were 816 veterans exposed to a home medicines review and 16,320 unexposed patients, with an average age of 81.5 years, and six to seven co-morbidities. Adjusted results showed a 79% reduction in likelihood of hospitalization for bleeding between 2 and 6 months (HR, 0.21 95% CI, 0.05-0.87) amongst those who had received a home medicines reviewed compared to the unexposed patients. No effect was seen in the time period from review to 2 months, nor in the time period 6 to 12 months post a review. Medicines review in the practice setting delays time to next hospitalization for bleeding in those treated with warfarin in the period 2 to 6 months after the review, but is not sustained over time. Six monthly medication reviews may be required for patients on warfarin who are considered at high risk of bleeding.

Retrospective Evaluation of Home Medicines Review by Pharmacists in Older Australian Patients Using the Medication Appropriateness Index

Home Medicines Review (HMR), a community-based collaborative service provided by general practitioners (GPs) and accredited pharmacists in Australia, has demonstrated effectiveness in preventing, detecting, and resolving medication-related problems. The Medication Appropriateness Index (MAI) has been found to be a reliable, valid, standardized instrument for assessment of multiple elements of drug therapy prescribing. To retrospectively evaluate the impact of HMRs on the appropriateness of prescribing, using the MAI as a tool to categorize pharmacists' recommendations. A retrospective analysis was performed on a sample of 270 HMR cases pertaining to community-dwelling older people (≥ 65 years) in New South Wales, Australia. The HMRs were collected from 7 accredited pharmacists using purposive sampling. All HMRs were conducted between February 2006 and October 2009. MAI scores were retrospectively calculated at baseline, after the HMR service based on the pharmacist's recommendations to the GP, and following uptake of the pharmacist's recommendations by the GP. The mean ± SD age of the patients was 75.3 ± 7.4 years and 55% were female. Overall, almost all (99%; n = 267) patients had at least 1 inappropriate rating at baseline and more than 50% (n = 154) of the patients had a cumulative MAI score >15. The mean MAI score at baseline was 18.6 ± 11.3, which decreased to 9.3 ± 7.5 after HMR. The number of patients with a cumulative MAI score ≤ 15 increased to 216 after the HMR service, compared to 116 at baseline. Pharmacists' recommendations documented in the HMR reports and uptake of these recommendations by the GP resulted in a statistically significant decrease in the MAI scores (both p < 0.001). The study demonstrates that the provision of medication reviews by accredited pharmacists can improve the appropriateness of prescribing as demonstrated by the change in MAI score and, hence, has the potential to improve patient outcomes. Pharmacists who perform medication reviews could also consider including the systematic approach of applying the MAI to assist in optimizing prescribing in older people.

Use of Evidence-Based Therapy for the Prevention of Cardiovascular Events Among Older people

Evidence-based therapies (EBTs) for the prevention of cardiovascular disease (CVD) are reportedly underutilized in older people. The primary purpose of this study was to evaluate the use of EBTs for the prevention of CVD events in older people and secondarily whether a Home Medicines Review (HMR) service by pharmacists' predicts the use of these medicines. A retrospective cross-sectional audit of HMR reports pertaining to 608 community-dwelling older people (>or=65 years) was conducted. EBTs considered for this audit included four guideline-recommended therapies for CVD: antithrombotic therapy (warfarin +/- antiplatelet therapy), beta-blockers, statins, and angiotensin agents (angiotensin-converting enzyme inhibitors [ACEI] +/- angiotensin II receptor blockers [ARBs]). The prevalence of EBT use among the older people, mean age (SD) 75.6 (7.5) years, was: 73% for antithrombotic therapy, 75% for statins, 74% for angiotensin therapy, and 35% for beta-blockers. CVD risk factors warranting treatment with these EBTs were frequently associated with use of EBTs. EBTs were least likely to be used in those with coronary interventions like coronary artery bypass grafting (CABG)/stent insertion (all EBTs except angiotensin agents) and angiotensin agents in those with a history of myocardial infarction or chronic heart failure. A pharmacist-led HMR service was significantly associated with the prescribing of all 4 EBTs. The results from this study show good adherence to evidence-based guidelines in general, although there is still room for improvement to further optimize clinical outcomes in these complex patients. The study also adds to the available literature on the effectiveness of pharmacists' collaborative contribution to the care of these high-risk patients.

Are interventions recommended by pharmacists during Home Medicines Review evidence‐based?

Over the past decade medication review services have been implemented in many countries, including Australia, UK and USA. Although, the attitudes and barriers to the implementation of evidence-based medicine have been investigated, the extent to which medication review recommendations are evidence-based is not known. To determine (1) the extent to which pharmacist's recommendations during medication review services were consistent with the evidence-based guides at the time of the review; and (2) the nature and extent of drug-related problems (DRPs) and the actions recommended by pharmacists to resolve DRPs. A retrospective review of Home Medicines Review cases performed on 224 community-dwelling older people (65 years or older). The chi-squared test for categorical variables was used to compare the proportion of recommendations that were evidence-based and recommendations for which no evidence could be identified in the most common Australian information sources. DRPs and the actions recommended to resolve the DRPs were classified according to previously employed criteria. Pharmacists made a total of 1114 therapeutic recommendations to general practitioners, of which 964 required supporting pharmacotherapeutic evidence. The majority (94%) of the pharmacists' recommendations were in accordance with the evidence-based guides, as compared with the recommendations for which no evidence could be identified (P < 0.001). Pharmacists reported that 98% of the patients had at least one problem with use of their medication detected. The majority of the actions recommended by pharmacists during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging, as highlighted by the DRPs identified in 98% of our patients. A suitably trained pharmacist, with full access to the patient, medical record and supporting resources, can help to improve the quality use of medicines in this at-risk population.

Prevalence of medication-related risk factors among retirement village residents: a cross-sectional survey

information on medication use and risk factors among older people residing in retirement villages and their uptake of medication reviews are scant. to identify medication use issues and risk factors for medication-related problems among retirement village residents and to evaluate the uptake of government-subsidised Home Medicines Review (HMR) services in this population. cross-sectional, mail survey. retirement villages in Victoria, Australia. members of the Residents of Retirement Villages of Victoria residing in retirement villages (2,116, aged 54-100 years). a questionnaire was developed incorporating validated scales and items to measure medication risk, medication adherence, co-morbidity, disability, information on medication use, health and the uptake of HMR services. Questionnaires were mailed to participants for self-completion and returned using reply-paid envelopes. of the 2,116 respondents (70.7% response rate), 2,006 (94.8%; 95% confidence interval (CI) 93.9-95.7%) reported using prescribed medications. Three or more health conditions were present in 993 (46.9%; 95% CI 44.8-49.0%) respondents. Five or more regular medications were used by 988 (46.7%; 95% CI 44.6-48.8%) respondents. Twelve or more tablets/capsules per day were used by 229 (10.8%; 95% CI 9.5-12.1%) respondents. The use of narrow therapeutic index medications was reported by 264 (12.5%; 95% CI 11.1-13.9%) respondents. Changes to medication regimens in the previous 3 months were reported by 356 (16.8%; 95% CI 15.2-18.4%) respondents. One or more medication-related risk factors were seen in 1,374 (64.9%; 95% CI 62.9-66.9%) respondents. Of these at-risk residents, 76 (5.5%; 95% CI 4.5-6.5%) reported receiving an HMR in the previous 12 months, who were older (P < 0.001), were using more medicines (P < 0.001) and had greater disability (P = 0.002). reasons for the low uptake of medication reviews in retirement village residents despite the high prevalence of medication risk require further investigation.

Drug related problems after discharge from an Australian teaching hospital

To reconcile patients' medicines and to classify drug related problems identified during medication review conducted after discharge from hospital. Patients were discharged from the cardiology unit of Westmead Hospital after recruitment into the Westmead Medicines Project which ran from 2004 to 2007. This retrospective study involved an analysis of drugs, diseases and drug related problems in medication review reports available for 76 out of 85 patients who received a Home Medicines Review (HMR). Data sources for medication reconciliation and analyses also included hospital discharge summaries (n = 70) and GP referrals for HMR (n = 44). Comprehensive clinical profiles were constructed for the 76 subjects whose drug related problems were identified, coded, and then classified from their HMR reports. Number, type, distribution and international classification of drugs, diseases and drug-related problems. Patients were prescribed drugs for a broad range of cardiovascular, circulatory, endocrine, respiratory and digestive system diseases. Mean number of drugs per patient in discharge summaries: 8.7 ± SD 3.3 (range 3-19); in GP referrals: 8.9 ± SD 4.3 (range 2-23); and in HMR reports: 10.8 ± SD 4.0 (range 3-24). Mean number of diseases per patient in discharge summaries: 4.1 ± SD 2.9 (range 1-11); and in HMR reports: 4.7 ± SD 2.6 (range 1-12). A total of 398 drug related problems were identified for 71 (93.3%) patients with mean 5.6 ± SD 4.3 problems (range 1-21). The most frequently recorded problems were the patients' uncertainty about drug aim: n = 128 (32.0%); potential interactions n = 89 (22.4%); and adverse reactions n = 60 (15.1%). This study showed that patients recently discharged from a tertiary care hospital had a significant number of drug related problems. Classification of drugs and diseases revealed a broad range of non-cardiovascular medicines and conditions in the patients from an acute care cardiology unit. We found that home medicines review provided continuity of care and an opportunity for medication reconciliation which revealed marked differences in number of drugs, between hospital discharge and medicines review. The patients' uncertainly about their drugs and their diverse range of co-morbidities indicated the need for timely counselling by pharmacists in the community.

Drug Burden Index and Potentially Inappropriate Medications in Community-Dwelling Older People

A significant problem in older people (aged >or=65 years) is the use of potentially inappropriate medications (PIMs), including those with sedative and anticholinergic properties. However, effective intervention strategies have yet to be identified. The Drug Burden Index (DBI) is an evidence-based tool that measures a person's total exposure to medications with sedative and anticholinergic properties and has been shown to be independently associated with impairment in cognitive and physical function. The main aim of the study was to investigate whether Home Medicines Review (HMR) services by pharmacists for community-dwelling older people would lead to an improvement in the use of medications, as measured by a decrease in the DBI score. The study also aimed to investigate the (i) distribution of DBI scores and PIMs among older people living in the community, and (ii) impact of pharmacists' recommendations on DBI scores and PIMs. A retrospective analysis of medication reviews was performed for 372 community-dwelling older people (aged >or=65 years) who received an HMR service from the pharmacist. The main outcome measure was the total DBI score at baseline and post-HMR. The data were also examined to determine the extent of PIM use (2003 Beers' criteria), and the number and nature of pharmacists' recommendations. Overall, medications contributing to the DBI (i.e. medications with sedative or anticholinergic properties) and PIMs were identified in 60.5% (n = 225) and 39.8% (n = 148) of the patients, respectively. Following pharmacist recommendations during the HMR service, medications contributing to the DBI were identified in 51.6% (n = 192) of the patients. A statistically significant reduction in the sum total of DBI scores for all patients was observed following pharmacists' recommendations during the HMR service (206.9 vs 157.3, p < 0.001). Pharmacists' recommendations also led to a decrease in the use of PIMs, which were identified in 28.2% (n = 105) of the patients following the HMR service. When the DBI is used for evaluation, pharmacists' recommendations during HMR services, if acted upon, may effect changes in the prescribing of sedative and anticholinergic medications, thereby substantially reducing the patient's drug burden. Future studies should focus on whether such a decrease may translate into functional improvements. The study also showed a positive influence of HMR services on the prescribing of PIMs.

Timeliness and Clinical Impact of Hospital‐Initiated Medication Reviews

ABSTRACTBackgroundMedication‐related problems often occur in the immediate post‐discharge period. To reduce medication misadventure the Commonwealth Government funds home medicines reviews (HMRs). HMRs are initiated when general practitioners refer consenting patients to their community pharmacists, who then engage accredited pharmacists to review patients' medicines in their homes.AimTo determine if hospital‐initiated medication reviews (HIMRs) can be implemented in a more timely manner than HMRs; and to assess the impact of a bespoke referral form with comorbidity‐specific questions on the quality of reports.MethodEligible medical inpatients at risk of medication misadventure were referred by the hospital liaison pharmacist to participating accredited pharmacists post‐discharge from hospital. Social, demographic and laboratory data were collected from medical records and during interviews with consenting patients. Issues raised in the HIMR reports were categorised: intervention/action, information given or recommendation, and assigned a rank of clinical significance.ResultsHIMRs were conducted within 11.6 ± 6.6 days post‐discharge. 36 HIMR reports were evaluated and 1442 issues identified – information given (n = 1204), recommendations made (n = 88) and actions taken (n = 150). The majority of issues raised (89%) had a minor clinical impact. The bespoke referral form prompted approximately half of the issues raised.ConclusionHIMRs can be facilitated in a more timely manner than post‐discharge HMRs. There was an associated positive clinical impact of issues raised in the HIMR reports.

The Effectiveness of Collaborative Medicine Reviews in Delaying Time to Next Hospitalization for Patients With Heart Failure in the Practice Setting

Background— Randomized controlled trials have demonstrated that collaborative medication reviews can improve outcomes for patients with heart failure. We aimed to determine whether these results translated into Australian practice, where collaborative reviews are nationally funded. Methods and Results— This retrospective cohort study using administrative claims data included veterans 65 years and older receiving bisoprolol, carvedilol, or metoprolol succinate for which prescribing physicians indicated treatment was for heart failure. We compared those exposed to a general practitioner–pharmacist collaborative home medication review with those who did not receive the service. The service includes physician referral, a home visit by an accredited pharmacist to identify medication-related problems, and a pharmacist report with follow-up undertaken by the physician. Kaplan-Meier analyses and Cox proportional hazards models were used to compare time until next hospitalization for heart failure between the exposed and unexposed groups. There were 273 veterans exposed to a home medicines review and 5444 unexposed patients. Average age in both groups was 81.6 years (no significant difference). The median number of comorbidities was 8 in the exposed group and 7 in the unexposed ( P &lt;0.0001). Unadjusted results showed a 37% reduction in rate of hospitalization for heart failure at any time (hazard ratio, 0.63; 95% CI, 0.44 to 0.89). Adjusted results showed a 45% reduction (hazard ratio, 0.55; 95% CI, 0.39 to 0.77) among those who had received a home medicines review compared with the unexposed patients. Conclusion— Medicines review in the practice setting is effective in delaying time to next hospitalization for heart failure in those treated with heart failure medicines.

Post-discharge medication reviews for patients with heart failure: a pilot study

Medication misadventure is greatest at times of change such as the transition from hospital to community. Patients with heart failure are prone to medication misadventure due to polypharmacy, inappropriate medication use and frequent readmissions. To identify the barriers encountered when implementing a Liaison Pharmacist facilitated post-discharge medication management service for patients with heart failure. A Liaison Pharmacist contacted the patient's General Practitioner (GP), sent them a medication discharge summary and organised an appointment for the patient with the GP approximately 2 days post-discharge to make a Home Medicines Review (HMR) referral. The patient's community pharmacist was also contacted, sent a medication discharge summary and requested to engage an accredited pharmacist to undertake the HMR. The Liaison Pharmacist arranged for the HMR report to be sent to the outpatient department clinic to enable assessment of outcomes at the outpatient department follow-up 12 weeks post-discharge. GP HMR referral rates. 90 patients were offered the service. Fifty-nine patients (66%) agreed to have their GP contacted with 56 GPs agreeing to order a HMR and 41 patients having an HMR post-discharge. Barriers to the implementation of a HMR post-discharge included: patient withdrawal, low GP awareness of the HMR process and conducting the HMR in a timely manner. This study provides evidence for the feasibility of a post-discharge pharmacy service for patients with heart failure although barriers to implementation have been identified.

Optimal Level of Liaison Pharmacist Intervention to Facilitate a Post‐Discharge Home Medicines Review

ABSTRACTBackgroundInterventions by hospital liaison pharmacists make general practitioners aware that the hospital deems it appropriate for their patient to have a post‐discharge home medicines review.AimTo determine the frequency of patient referrals for a post‐discharge home medicines review by general practitioners using two less resource intensive models than that previously developed at the Royal Adelaide Hospital.MethodPatients were randomly assigned to either Group A or Group B. Group A patients were counselled about the benefits of an home medicines review and their general practitioner and community pharmacist were sent a medication discharge summary highlighting the hospital's suggestion for a postdischarge home medicines review (standard care). Group B patients received standard care plus their medication discharge summaries included reasons for why an home medicines review was recommended, the community pharmacist's contact details were provided, and a general practitioner appointment was also made via a practice nurse/receptionist.ResultsThe lower level of intervention in Group A patients resulted in a 7% home medicines review referral rate while a higher level of intervention in Group B patients resulted in a 53% home medicines review referral rate (p = 0.0052).ConclusionThe Group B model resulted in a significantly higher general practitioner referral rate when compared to ‘standard care'. A compromise in referral rates occurs if a less resource intensive model is used compared to the previously developed resource intensive model involving the liaison pharmacist.