Home Medicines Review Service Research Articles

Impact of Home Medicines Review on medication regimen complexity

AbstractBackgroundPrevious studies on pharmacist‐led Home Medicines Review (HMR) have demonstrated positive associations of HMR and clinical outcomes. However, little is known about their impact on medication regimen complexity.AimInvestigate the impact of pharmacist‐led HMRs on simplifying medication regimen complexity using the Medication Regimen Complexity Index (MRCI).MethodA retrospective cohort study of 196 general practitioners (GPs) initiated HMRs, conducted over a period of 2 years (2020–2022) using two credentialed pharmacists in New South Wales, Australia. MRCI was used to measure the complexity at two separate time points, at baseline and following pharmacists' recommendations (assuming the GPs accepted all of the pharmacists' recommendations provided during the HMRs). The Wilcoxon signed‐rank test was used to determine the difference between the scores at baseline and after HMR. Ethical approval was granted by the University of Sydney Human Research Ethics Committee (Reference no: 2022/584) and the study conforms to the Australian National statement on the ethical conduct in human research.ResultsDuring the HMR service, pharmacists made a total of 792 recommendations (mean ± standard deviation [4.04 ± 2.3] per HMR), among which dosage and frequency adjustment, laboratory monitoring, and therapeutic monitoring were the most common, collectively accounting for almost half of the recommendations. The median MRCI score at baseline was 28.5 (interquartile range [IQR] 21.5–37.6) and following pharmacists' recommendations was 29 (IQR 21.9–37.1). The difference between the baseline and post‐HMR scores was not statistically significant.ConclusionOur study demonstrates the lack of significant reductions in medication complexity following HMRs as measured by the MRCI. However, these results need to be interpreted with caution as not all interactions with patients lead to a change in the MRCI score. Comprehensive examination of individual medication changes may provide more meaningful and clinically relevant inferences.

Home medicines reviews: a national survey of Australian accredited pharmacists' health service time investment.

Background:In Australia, polypharmacy and medication-related problems are prevalent in the community. Therefore, medicines safety initiatives such as the Home Medicines Review (HMR) service are critical to health care provision. While the evidence continues to expand around HMR service, little is known of accredited pharmacists’ experiences of HMR time investment.Objective:This study aimed to explore accredited pharmacists’ experiences of HMR practice regarding time investment in the study’s defined HMR Stages: 1 (initial paper-based assessment and review), 2 (in-home patient-accredited pharmacist consultation), and 3 (HMR report collation, generation, completion, and provision to the patient’s General Practitioner, including any liaison time).Methods:An electronic survey was developed and piloted by a panel of reviewers. Convenience sampling was used to distribute the final anonymous survey nationally via professional pharmacy organisations. Data were analyzed for frequency distributions and a chi-square test of independence was performed to evaluate any association between demographic variables relating to HMR time investment.Results:There was a total of 255 survey respondents, representing approximately 10% of national accredited pharmacist membership. The majority were experienced accredited pharmacists who had completed >100 HMRs (73%), were female (71%), and aged >40 years (60%). Regarding time investment for a typical instance of HMR, most spent: <30 minutes performing Stage 1 (46.7%), and 30-60 minutes performing Stage 2 (70.2%). In Stage 3, 40.0% invested 1-2 hours, and 27.1% invested 2-3 hours in HMR report collation and completion. Quantitative analysis revealed statistically significant (p=0.03) gender findings where females performed longer patient consultations than males (Stage 2). More HMR career experience resulted in statistically significant (p=0.01) less time performing Stage 1 (initial paper-based assessment and review); with a trend to less time performing Stage 3 (HMR report writing).Conclusions:Accredited pharmacists invest significant time in performing comprehensive HMRs, especially during in-home patient consultations and during HMR report collation and completion. Their significant HMR time investment as medicines experts provides insight for program and workforce considerations and warrants further research to better understand their work processes for optimizing medicines use and improving health.

Implementation of the Goal-directed Medication review Electronic Decision Support System (G-MEDSS)\xa9 into home medicines review: a protocol for a cluster-randomised clinical trial in older adults

BackgroundOlder people living in the community have a high prevalence of polypharmacy and are vulnerable to adverse drug events. Home Medicines Review (HMR) is a collaborative medication review service involving general practitioners (GPs), accredited clinical pharmacists (ACPs) and patients, which aims to prevent medication-related problems. This study aims to evaluate the implementation of a Computerised Clinical Decision Support System (CCDSS) called G-MEDSS© (Goal-directed Medication Review Electronic Decision Support System) in HMRs to deprescribe anticholinergic and sedative medications, and to assess the effect of deprescribing on clinical outcomes.MethodsThis study consists of 2 stages: Stage I – a two-arm parallel-group cluster-randomised clinical trial, and Stage II – process evaluation of the CCDSS intervention in HMR. Community-dwelling older adults living with and without dementia who are referred for HMR by their GP and recruited by ACPs will be included in this study. G-MEDSS is a CCDSS designed to provide clinical decision support for healthcare practitioners when completing a medication review, to tailor care to meet the patients’ goals and preferences. The G-MEDSS contains three tools: The Goals of Care Management Tool, The Drug Burden Index (DBI) Calculator©, and The revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire. The G-MEDSS produces patient-specific deprescribing reports, to be included as part of the ACPs communication with the patient’s GP, and patient-specific reports for the patient (or carer). ACPs randomised to the intervention arm of the study will use G-MEDSS to create deprescribing reports for the referring GP and for their patient (or carer) when submitting the HMR report. ACPs in the comparison arm will provide the usual care HMR service (without the G-MEDSS).OutcomesThe primary outcome is reduction in DBI exposure 3 months after HMR ± G-MEDSS intervention between comparison and intervention groups. The secondary outcomes include changes in clinical outcomes (physical and cognitive function, falls, institutionalisation, GP visits, medication adherence and mortality) 3-months after HMR.DiscussionThis study is expected to add to the evidence that the combination of CCDSS supporting medication review can improve prescribing and clinical outcomes in older adults.Trial registrationThe trial was registered on the Australian New Zealand Clinical Trials Registry ACTRN12617000895381 on 19th June 2017.

Evaluation of a home medicines review program at an Aboriginal Medical Service in the Northern Territory

AbstractBackgroundThe home medicines review (HMR) program aims to achieve quality use of medicines. In 2009, the model of HMR provision at Danila Dilba Health Service (DDHS) in Darwin was adjusted to include the services of a dedicated consultant pharmacist and an expanded role for an Aboriginal Health Worker (AHW) in the HMR process.AimThis study evaluated a unique program providing HMRs to Indigenous clients of DDHS.MethodsA retrospective review of HMRs was conducted for clients at DDHS between December 2009 and December 2010 to determine relevant time frames between HMR activities, reasons for referral, issues identified by the pharmacist, education provided, recommendations and uptake of recommendations. Awareness and attitudes to the program among general practitioners (GPs), AHWs, and pharmacists were also evaluated using a self‐administered questionnaire.ResultsSixty‐four HMRs were conducted. Thirty‐nine (61%) follow‐up appointments were documented and 30 Medicare claims made. The average time between referral and follow‐up was 66 days. For most HMRs, more than one reason for referral was identified. In all, 348 issues were identified, 256 educational activities undertaken and 379 recommendations made. Fifty‐two per cent of recommendations were implemented. Attitudes to the HMR program were positive. Common themes included the importance of cultural safety, particularly the inclusion of an AHW in HMR activities and difficulties associated with the follow‐up of patients.ConclusionUptake of recommendations for improvements in the quality of documentation, GP follow‐up and the referral system will enhance the HMR service at DDHS.

General practitioners' perceptions on home medicines reviews: a qualitative analysis.

BackgroundHome Medicines Review (HMR) is an Australian initiative introduced in 2001 to improve quality use of medicines. Medication management services such as HMRs have the potential to reduce medication related problems. In 2011, changes to the HMR program were introduced to allow for referrals directly to accredited pharmacists in addition to the community pharmacy referral model. These changes were introduced to improve efficiency of the process. This study explored the perceptions of Western Australian general practitioners (GPs) on benefits and barriers of the HMR service and process, including their insights into the direct referral model.MethodsPurposive sampling of GPs who had experience ensured that participants had a working knowledge of the HMR service. Semi structured interviews with 24 GPs from 14 metropolitan Western Australian medical centres between March and May 2013. Transcribing and thematic analysis of data were performed.ResultsMost GPs had positive attitudes towards the HMR service. Main perceived benefits of the service were poly-pharmacy reduction and education for both the GP and patient. Strategies identified to improve the service were introduction of a standard HMR report template for pharmacists and better use of technology. Whilst reliability and GPs’ familiarity were the main perceived benefits of the direct referral model, a number of GPs agreed that patient unfamiliarity with the HMR pharmacist was a barrier.ConclusionsDespite recognition of the value of the HMR service participating GPs were of the opinion that there are aspects of the HMR service that could be improved. As one of the success factors of HMRs is relying on GPs to utilise this service, this study provides valuable insight into issues that need to be addressed to improve HMR uptake.

Implementation of pharmacist-led medication reviews in general practice

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.

Exploring stakeholder perspectives on medication review services for older residents in retirement villages

To explore stakeholder perspectives on a government-subsidised Home Medicines Review (HMR) service and factors affecting the uptake of HMRs for older residents of retirement villages in Australia. Thirty-two in-depth interviews and four focus groups were undertaken with a purposive sample of 32 residents of retirement villages, 10 pharmacists, nine general practitioners (GPs) and a general practice nurse. Data were transcribed verbatim and analysed using the framework approach. Three major themes were identified: participants' perceptions of the HMR service, barriers to the uptake of HMRs and strategies for increasing the uptake of HMR. Residents had positive, negative or mixed perceptions, whereas health professionals were generally positive about the benefits of the service. Barriers to the uptake of HMRs were related to GPs, pharmacists, patients and the healthcare system. A strategy recommended by multiple stakeholders for increasing the uptake of HMRs was to use a multi-faceted intervention targeting residents and their health professionals. Multiple barriers to the uptake of HMRs and multiple strategies for increasing the uptake of HMRs were identified. These findings could inform the design of interventions to improve uptake of HMRs by residents and health professionals, in turn leading to better medicine use and safety.

Home Medicines Reviews: a quantitative study of the views of recipients and eligible non-recipients

There is a lack of knowledge regarding recipients' experiences with, perceptions of, and willingness to reuse the Home Medicines Review (HMR) programme in Australia. In addition, little is known about eligible non-recipients' awareness of and willingness to use the HMR service. The aim of the study was therefore to explore perceptions of, and willingness to use, HMRs. A cross-sectional questionnaire was conducted with recipients and eligible non-recipients of HMRs. Eligible non-recipients were defined as those who had not had an HMR and were at risk of medication misadventure. The questionnaire was distributed by 264 practising pharmacists throughout Australia. A total of 595 out of 1893 (31%) HMR recipients and 293 out of 1829 (16%) eligible non-recipients completed the questionnaires. Overall, 91% of recipients were satisfied with the service. Compared with eligible non-recipients, recipients were more willing to have an HMR if their general practitioner (GP) suggested it (91% versus 71%, P < 0.001) and more willing to ask for an HMR if they were having concerns about their medicines (82% versus 63%, P < 0.001). Among eligible non-recipients, 23% were aware of HMRs. Predominantly pharmacists (68%) and GPs (36%) provided awareness of HMRs, which was associated with increased willingness to have an HMR if their GP suggested it (83% versus 67%, P < 0.014). An overwhelming majority of patients were satisfied with the HMR programme. Experience with HMR, and to a lesser extent, prior awareness, increased willingness to use HMR. Therefore, pharmacists and GPs who introduce HMR to eligible non-recipients may increase their willingness to use this service.

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.

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.

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.

Enhancing Continuity of Care in Therapeutics: Development of a Post‐Discharge Home Medicines Review Model

ABSTRACTBackgroundThe Australian Pharmaceutical Advisory Council guidelines for the continuum of quality use of medicines between hospital and community aim to establish a coordinated approach that encourages continuity in all areas of health care and the community. However, the implementation of these guidelines has been problematic.AimTo identify the number and nature of barriers encountered when organising a home medicines review (HMR) for patients at high risk of medication misadventure, after discharge from hospital.MethodA liaison pharmacist organised an appointment for eligible patients (around 2 days post‐discharge) for the general practitioner to make an HMR referral. The pharmacist contacted the patient's community pharmacist to engage an accredited pharmacist to undertake the HMR and arranged for the HMR report to be sent to the outpatient clinic, the general practitioner and community pharmacist.Results38/50 patients consented to have their general practitioner contacted by the liaison pharmacist. General practitioners agreed to order an HMR for 34 patients. Barriers to HMR uptake included: low patient awareness of HMRs, a low level of general practitioner awareness of the HMR process, reluctance of some community pharmacists to participate in HMR delivery and the time taken for HMRs to be performed.ConclusionOnce aware of the HMR service, the majority of patients were willing to participate and general practitioners were prepared to refer their patients for such a service. However, time constraints impacted on both general practitioners and community pharmacists, hence, consideration should be given to extending the support from HMR facilitators to include pharmacies as well as general practitioners.