Medication Reviews In Primary Care Research Articles

Lack of medication reviews in primary care contribute to patient deaths – thematic review of prevention of future deaths reports 2019-2023

Abstract Introduction With over 1 billion items dispensed in primary care each year, practices need robust systems to review repeat prescriptions and safeguard patients.1 The Care Quality Commission have reviewed areas of harm in relation to medicines.2 In general practice, errors in monitoring and review of repeat prescriptions create potential for harm and in some circumstances, death. When reviewing medicines-related patient deaths, coroners may write prevention of future deaths reports (PFDs) to highlight matters of concern to a person or organisation who may have power to act.3 Aim This retrospective case series aims to review coroners’ PFD reports over a 5-year period, with a focus on medicines-related deaths. The review will identify key themes, the most commonly prescribed medicines and any relevant patient demographics. Changes will be suggested to practice for any areas of concern or trends identified. Methods PFDs published on the judiciary website between 1st January 2019 and 31st December 2023 which reported on medication-related deaths were screened.3 Those relating to repeat prescribing were selected for analysis. Inductive thematic analysis was used to assess PFDs and identify where failures in repeat prescribing processes contributed to medication-related deaths. The “Matters for Concern” were reviewed by three research collaborators, who independently coded the data and identified the key themes. Following the initial screening process, demographic data (if known), relevant coroner notes, and available information on the drug(s) which contributed to patient deaths were extracted from the PFDs and recorded in a data table in Microsoft Excel. Ethical approval was not required as the research used publicly available information. Results 24 of 4781 PFDs related to repeat prescribing. The majority reported were female patients (67%, p<0.05) with average age of 48. Although the geographic distribution of PFDs was varied, a substantial proportion were published in Greater Manchester (9/24 38%). 76% of named medications were opioid analgesics, mentioned significantly more than any others (p<0.05). One third of the included PFDs described polypharmacy or repeat prescriptions taken alongside acute or over-the-counter medications. 57 matters of concern were raised by coroners, from which three key themes were identified: errors or discrepancies at the point of a transfer of care; the ability to obtain repeat prescriptions from multiple medication sources and a lack of robust medication review. Absence of medication review occurred most frequently (15/24 reports, 63%). Discussion This study identified where risks lie in repeat prescribing processes, with lack of robust medication reviews being most commonly linked to patient deaths. Inherently high-risk medicines, opioid analgesics, were most commonly described and should be prioritised for review. The average age was 48, suggesting older age may not be a risk factor in itself, but the contribution of polypharmacy was emphasised in the reports. The sample size was small and the time to extract the information from the reports impacted on the length of the study period chosen. However, pharmacy teams in general practice have an essential role to play in supporting medication reviews. Development of guidance to support repeat prescribing will also help to better safeguard patients receiving repeat medication.

Exploring stakeholders’ views of pharmacist-led medication reviews in general practice

Abstract Introduction Medication reviews are a widely implemented intervention to support patients who are prescribed multiple medicines or those with complex medication regimens. The more medicines a patient takes, the higher the chance of them experiencing harmful effects. Despite the extensive use of medication reviews, the proportion of patients who experience poor medicines outcomes such as adverse drug reactions and hospitalisations has not altered significantly in ten years. Pharmacists have been introduced to general practice to help to improve patient access to medication reviews. Aim The aim of this study was to explore pharmacists’, patients’, and general practitioners’ (GPs’) opinions and experience of medication reviews in general practice. Methods We held one focus group with patients and one with pharmacists. As the two GPs were unable to attend the focus group with the pharmacists, they were individually interviewed. Purposive sampling was used to select participants with a range of ethnicity, gender, age, and geographical mix. Reflexive thematic analysis of the focus group and interview transcripts was undertaken by one researcher (MC) to identify themes.[1] Results Seven patients, five pharmacists, and two general practitioners participated in this study. Two main themes were generated. Theme one: preparing for the review. Subtheme one: time to prepare. Patients require advance notice of their review so they can be prepared with queries. Pharmacists need sufficient time to familiarise themselves with the patient’s history and perform the necessary clinical checks. Subtheme two: education about medication reviews. Some patients do not understand the purpose or process of a medication review and can be reticent to engage. Subtheme three: suitability of appointments. Longer face-to-face appointments usually benefit patients with complex medication regimens, or patients with communication difficulties. Patients who have simple regimens or are happy with their medicines may be content with a telephone or online review. Theme two: conducting the medication review. Subtheme one: establish the aim of the review. Patients present for medication reviews for different reasons (e.g., a clinical issue has been identified, patients meet defined criteria or take specific medicines); therefore, the aim of the review should be established at the beginning. Subtheme two: involve and engage the patient. Patients want to feel that they have been listened to and supported during the medication review. Patients want more opportunities to ask questions and/or raise their concerns in the review. Subtheme three: defined but flexible process for the review. Pharmacists and GPs acknowledged the use of templates and guidance to deliver medication reviews, but stressed the importance of tailoring the medication review to meet the needs of the patient. Conclusion Whilst recruitment was challenging, the variety of participants provided a multi-perspective view of medication reviews and a rich source of data. GPs interviews provided a good source of data, but it is possible that different sub-themes may have been generated from integrated discussions. The themes identified provide an outline of the implementation of pharmacist-led medication reviews in general practice. These can be used to support future work to optimise medication reviews in primary care.

A qualitative exploration of barriers to efficient and effective structured medication reviews in primary care: Findings from the DynAIRx study.

Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them. Qualitative focus groups and semi-structured interviews took place between 2022-2023. Six focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n = 21), and three patient focus groups with patients with multimorbidity (n = 13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using thematic analysis. Two key themes limiting the effectiveness of SMRs in clinical practice were identified: 'Medication Reviews in Practice' and 'Medication-related Challenges'. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication. SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems.

What makes a multidisciplinary medication review and deprescribing intervention for older people work well in primary care? A realist review and synthesis

BackgroundA third of older people take five or more regular medications (polypharmacy). Conducting medication reviews in primary care is key to identify and reduce/ stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach. Our aim was to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDTs) work (or do not work) for older people.MethodsA realist synthesis following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidelines was completed. A scoping literature review informed the generation of an initial programme theory. Systematic searches of different databases were conducted, and documents screened for eligibility, with data extracted based on a Context, Mechanisms, Outcome (CMO) configuration to develop further our programme theory. Documents were appraised based on assessments of relevance and rigour. A Stakeholder consultation with 26 primary care health care professionals (HCPs), 10 patients and three informal carers was conducted to test and refine the programme theory. Data synthesis was underpinned by Normalisation Process Theory to identify key mechanisms to enhance the implementation of MDT medication review and deprescribing in primary care.FindingsA total of 2821 abstracts and 175 full-text documents were assessed for eligibility, with 28 included. Analysis of documents alongside stakeholder consultation outlined 33 CMO configurations categorised under four themes: 1) HCPs roles, responsibilities and relationships; 2) HCPs training and education; 3) the format and process of the medication review 4) involvement and education of patients and informal carers. A number of key mechanisms were identified including clearly defined roles and good communication between MDT members, integration of pharmacists in the team, simulation-based training or team building training, targeting high-risk patients, using deprescribing tools and drawing on expertise of other HCPs (e.g., nurses and frailty practitioners), involving patents and carers in the process, starting with ‘quick wins’, offering deprescribing as ‘drug holidays’, and ensuring appropriate and tailored follow-up plans that allow continuity of care and management.ConclusionWe identified key mechanisms that could inform the design of future interventions and services that successfully embed deprescribing in primary care.

‘Something that Facilitates Our Work…Rather than a Hindrance’: Clinical Pharmacist Perspectives on the Use of Data Analytics to Support Polypharmacy Medication Review In Primary Care

‘Something that Facilitates Our Work…Rather than a Hindrance’: Clinical Pharmacist Perspectives on the Use of Data Analytics to Support Polypharmacy Medication Review In Primary Care

Association between recorded medication reviews in primary care and adequate drug treatment management – a cross-sectional study

Objective To investigate the association between a recorded procedure code for a medication review and adequate drug treatment management, and to explore factors associated with this code. Design and setting Cross-sectional study; two primary health care centres, in Region Västra Götaland, Sweden. Subjects A total of 302 consecutive patients (≥65 years old, 59% female; median number of drugs: six) requiring a non-urgent consultation with a physician in October–November 2017. Main outcome measure Adequate drug treatment management (treatment that did not require any further action), determined in consensus by two specialists in family medicine blinded to the medication review code. Results Adequate drug treatment management was, overall, less common in those with a recorded medication review over the last year: 63% versus 73% (p = 0.047). This negative association was evident among patients aged 65–74 years: 49% versus 74% (p = 0.003), but absent in those ≥75 years old: 67% versus 70% (p = 0.77). Recommendations from consensus included the search for additional information to be able to make a decision regarding initiation or withdrawal of a drug (n = 53), withdrawal of a drug (n = 41), or ordering a laboratory test (n = 25). Factors associated with a recorded procedure code included age above the remuneration limit of 75 years (odds ratio: 9.8; 95% confidence interval 5.0–19), type 2 diabetes (3.0 (1.5–6.2)), hypertension (2.4 (1.2–4.8)), and depression (2.5 (1.02–6.0)). Conclusions The presence of a recorded medication review was not positively associated with adequate drug treatment management but was associated with the age limit for remuneration, and some chronic diseases. Key points To improve drug treatment in older people in primary care, a remuneration system linked to recorded medication reviews has been introduced. In this study, fewer patients with than without a recorded medication review (63% versus 73%) had adequate drug treatment management. A recorded medication review was ten times more common in those ≥75 years, that is, the age limit for remuneration. Recorded codes for medication reviews were also common in those with type 2 diabetes, hypertension, and depression.

The role of trust and hope in antipsychotic medication reviews between GPs and service users a realist review

BackgroundIncreasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support.AimTo explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input.Design & settingRealist review in general practice settings.MethodA realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews.ResultsMeaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory.ConclusionsThe review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

BackgroundMedication reviews for people transitioning from one healthcare setting to another potentially improve health outcomes, although evidence for outcome benefits varies. It is unclear when and why medication reviews performed...

For which patient subgroups are there positive outcomes from a medication review? A systematic review.

Background:A medication review is a possibility to assess and optimise a patient’s medicine. A model that includes a medication review and a follow-up seem to provide the best results. However, it is not known whether specific subgroups of patients benefit more from a medication review than others.Objective:This literature review summarises the evidence that is available on which patient subgroups exist positive outcomes from a medication review carried out in a primary care setting.Methods:We performed a PICO analysis to identify keywords for setting, medication review and effect. We then conducted a search using the PubMed database (2004 to 2019) to identify studies relevant for our investigation. A screening process was carried out based on either title or abstract, and any study that matched the aim and inclusion criteria was included. All matching studies were obtained and read, and were included if they met predefined criteria such as study design, medication review and primary care. The studies were divided into subgroups. First, each subgroup was divided according to the studies’ own definition. Secondly, each subgroup was allocated as either risk patients if the subgroup described a specific patient subgroup or risk medication, if the subgroup was defined as using a specific type of medication. This was done after discussion in the author group.Results:28 studies from a total of 935 studies were included. Identified studies were divided into either risk patients; frail, recently discharged or multimorbid patients, or risk medication; heart medication, antithrombotic medication, blood pressure lowering medication, antidiabetic medication, anti-Parkinson medication or medication increasing the risk of falls. The subgroups identified from a medication review in primary care were defined as being frail, recently discharged from hospital or multimorbid (risk patients), or defined as patients using anticoagulant or blood pressure lowering medication (risk medication). Most of the medication reviews in the studies that showed an economic effect included at least one follow-up and were delivered by a pharmacist.Conclusions:The literature review demonstrates that medication reviews delivered by pharmacists to specific subgroups of patients are a way of optimising the economic effect of medication reviews in primary care. This is obtained by reducing health-related costs or the number of contacts with primary or secondary health care services.

Patient-perceived barriers and facilitators to the implementation of a medication review in primary care: a qualitative thematic analysis

BackgroundAlthough polypharmacy can cause adverse health outcomes, patients often know little about their medication. A regularly conducted medication review (MR) can help provide an overview of a patient’s medication, and benefit patients by enhancing their knowledge of their drugs. As little is known about patient attitudes towards MRs in primary care, the objective of this study was to gain insight into patient-perceived barriers and facilitators to the implementation of an MR.MethodsWe conducted a qualitative study with a convenience sample of 31 patients (age ≥ 60 years, ≥3 chronic diseases, taking ≥5 drugs/d); in Hesse, Germany, in February 2016. We conducted two focus groups and, in order to ensure the participation of elderly patients with reduced mobility, 16 telephone interviews. Both relied on a semi-structured interview guide dealing with the following subjects: patients’ experience of polypharmacy, general design of MRs, potential barriers and facilitators to implementation etc. Interviews were audio-recorded, transcribed verbatim, and analysed by two researchers using thematic analysis.ResultsPatients’ average age was 74 years (range 62–88 years). We identified barriers and facilitators for four main topics regarding the implementation of MRs in primary care: patient participation, GP-led MRs, pharmacist-led MRs, and the involvement of healthcare assistants in MRs. Barriers to patient participation concerned patient autonomy, while facilitators involved patient awareness of medication-related problems. Barriers to GP-led MRs concerned GP’s lack of resources while facilitators related to the trusting relationship between patient and GP. Pharmacist-led MRs might be hindered by a lack of patients’ confidence in pharmacists’ expertise, but facilitated by pharmacies’ digital records of the patients’ medications. Regarding the involvement of healthcare assistants in MRs, a potential barrier was patients’ uncertainty regarding the extent of their training. Patients could, however, imagine GPs delegating some aspects of MRs to them.ConclusionsOur study suggests that patients regard MRs as beneficial and expect indications for their medicines to be checked, and possible interactions to be identified. To foster the implementation of MRs in primary care, it is important to consider barriers and facilitators to the four identified topics.

MEDICATION REVIEW OF CHILDREN ON LONG TERM MEDICATIONS: A REVIEW OF THE LITERATURE

IntroductionChildren on long term medication may be under the care of more than one medical team including the patients GP. Children on chronic medication should be supported and their medications...

Improving the Effectiveness of Medication Review: Guidance from the Health Literacy Universal Precautions Toolkit.

Although routine medication reviews in primary care practice are recommended to identify drug therapy problems, it is often difficult to get patients to bring all their medications to office visits. The objective of this study was to determine whether the medication review tool in the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit can help to improve medication reviews in primary care practices. The toolkit's "Brown Bag Medication Review" was implemented in a rural private practice in Missouri and an urban teaching practice in California. Practices recorded outcomes of medication reviews with 45 patients before toolkit implementation and then changed their medication review processes based on guidance in the toolkit. Six months later we conducted interviews with practice staff to identify changes made as a result of implementing the tool, and practices recorded outcomes of medication reviews with 41 additional patients. Data analyses compared differences in whether all medications were brought to visits, the number of medications reviewed, drug therapy problems identified, and changes in medication regimens before and after implementation. Interviews revealed that practices made the changes recommended in the toolkit to encourage patients to bring medications to office visits. Evaluation before and after implementation revealed a 3-fold increase in the percentage of patients who brought all their prescription medications and a 6-fold increase in the number of prescription medications brought to office visits. The percentage of reviews in which drug therapy problems were identified doubled, as did the percentage of medication regimens revised. Use of the Health Literacy Universal Precautions Toolkit can help to identify drug therapy problems.

Supervised pharmacy student-led medication review in primary care for patients with type 2 diabetes: a randomised controlled pilot study

ObjectiveTo pilot and feasibility-test supervised final year undergraduate pharmacy student-led medication reviews for patients with diabetes to enable definitive trial design.MethodThird year pharmacy students were recruited from one UK School...

Computerized Decision Support Improves Medication Review Effectiveness: An Experiment Evaluating the STRIP Assistant's Usability.

BackgroundPolypharmacy poses threats to patients’ health. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) is a drug optimization process for conducting medication reviews in primary care. To effectively and efficiently incorporate this method into daily practice, the STRIP Assistant—a decision support system that aims to assist physicians with the pharmacotherapeutic analysis of patients’ medical records—has been developed. It generates context-specific advice based on clinical guidelines.ObjectiveThe aim of this study was to validate the STRIP Assistant’s usability as a tool for physicians to optimize medical records for polypharmacy patients.MethodsIn an online experiment, 42 physicians were asked to optimize medical records for two comparable polypharmacy patients, one in their usual manner and one using the STRIP Assistant. Changes in effectiveness were measured by comparing respondents’ optimized medicine prescriptions with medication prepared by an expert panel of two geriatrician-pharmacologists. Efficiency was operationalized by recording the time the respondents took to optimize the two cases. User satisfaction was measured with the System Usability Scale (SUS). Independent and paired t tests were used for analysis.ResultsMedication optimization significantly improved with the STRIP Assistant. Appropriate decisions increased from 58 % without the STRIP Assistant to 76 % with it (p < 0.0001). Inappropriate decisions decreased from 42 % without the STRIP Assistant to 24 % with it (p < 0.0001). Participants spent significantly more time optimizing medication with the STRIP Assistant (24 min) than without it (13 min; p < 0.0001). They assigned it a below-average SUS score of 63.25.ConclusionThe STRIP Assistant improves the effectiveness of medication reviews for polypharmacy patients.

Effects of a pharmacist-led structured medication review in primary care on drug-related problems and hospital admission rates: a randomized controlled trial

Objective. To determine whether a pharmacist-led medications review in primary care reduces the number of drugs and the number of drug-related problems. Design. Prospective randomized controlled trial. Setting. Liljeholmen Primary Care Centre, Stockholm, Sweden. Subjects. 209 patients aged ≥ 65 years with five or more different medications. Intervention. Patients answered a questionnaire regarding medications. The pharmacist reviewed all medications (prescription, non-prescription, and herbal) regarding recommendations and renal impairment, giving advice to patients and GPs. Each patient met the pharmacist before seeing their GP. Control patients received their usual care. Main outcome measures. Drug-related problems and number of drugs. Secondary outcomes included health care utilization and self-rated health during 12 months of follow-up. Results. No significant difference was seen when comparing change in drug-related problems between the groups. However, a significant decrease in drug-related problems was observed in the intervention group (from 1.73 per patient at baseline to 1.31 at follow-up, p < 0.05). The change in number of drugs was more pronounced in the intervention group (p < 0.046). Intervention group patients were not admitted to hospital on fewer occasions or for fewer days, and there was no significant difference between the two groups regarding utilization of primary care during follow-up. Self-rated health remained unchanged in the intervention group, whereas a drop (p < 0.02) was reported in the control group. This resulted in a significant difference in change in self-rated health between the groups (p < 0.047). Conclusions. The addition of a skilled pharmacist to the primary care team may contribute to reductions in numbers of drugs and maintenance of self-rated health in elderly patients with polypharmacy.

Pharmacist-led medication reviews in primary care

SummaryMedication reviews in primary care are now an established and important part of the care of patients on multiple medications. In the current NHS this review has demonstrated that pharmacist-led medication reviews can reduce inappropriate prescribing and offer an efficient approach to ensuring reviews are completed. These reviews appear best operationalized with experienced pharmacists who are closely aligned with the patients and prescribers through joined up services. Further developments in pharmacists’ communication skills with patient and prescribers may offer greater benefits in the future.

Medication reviews in primary care

Medication reviews are becoming increasingly important in primary care, as the need to reduce the wastage of medications in order to save money increases. It is estimated that 50% of drugs are not taken as prescribed, and 5–17% of hospital admissions are a consequence of adverse reaction to medication ( Department of Health (DH), 2001 ). A medication review may be conducted by a nurse, doctor or pharmacist, provided they have the appropriate therapeutic knowledge and clinical experience. There are three levels of medication review. Level 1 is a prescription review. Level 2 involves a review of medicines using the patient's notes. Level 2 enhanced also includes a telephone discussion with the patient. Level 3 is a clinical medication review, involving face-to-face contact with the patient. Medication reviews are important for concordance, as they enable a patient to understand why they are taking a particular medication. Given the pressure on appointments in primary care, level 3 reviews may not always be feasible and indeed in many cases would be inappropriate and could annoy patients. Medication reviews should target those most likely to benefit. This would include the frail elderly with multiple co-morbidity and polypharmacy and those with frequent hospital admissions.

The General Practitioner–Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews in community pharmacy

There are conflicting results in studies of pharmacists undertaking medication reviews for older people. With increasing promotion and funding for 'medication reviews' there is a need for them to be standardised, and to determine their effectiveness and the feasibility of providing them from a community pharmacy. The objective was to determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine-related therapeutic outcomes for patients. A randomised controlled trial was carried out in people 65 years and older on five or more prescribed medicines. Community pharmacists undertook a clinical medication review (Comprehensive Pharmaceutical Care) and met with the patient's general practitioner to discuss recommendations about possible medicine changes. The patients were followed-up 3-monthly. The control group received usual care. The main outcome measures were Quality of Life (SF-36) and Medication Appropriateness Index. A total of 498 patients were enrolled in the study. The quality-of-life domains of emotional role and social functioning were significantly reduced in the intervention group compared to the control group. The Medication Appropriateness Index was significantly improved in the intervention group. Only 39% of the 44 pharmacists who agreed to participate in the study provided adequate data, which was a limitation of the study and indicated potential barriers to the generalisability of the study. Clinical medication reviews in collaboration with general practitioners can have a positive effect on the Medication Appropriateness Index. However, pharmacist withdrawal from the study suggests that community pharmacy may not be an appropriate environment from which to expand clinical medication reviews in primary care.

Preventing drug-related morbidity--determining valid indicators.

To describe the process that is being undertaken to validate a series of indicators for preventable drug-related morbidity - originally developed in the US - for application in the UK health care system. A two-round Delphi questionnaire survey after a preliminary validation of the indicators within the University of Manchester School of Pharmacy. A primary care study set in the UK. A purposively selected sample of general practitioners with a specific responsibility for prescribing-related issues (n = 6) and pharmacists actively involved in medication review in primary care (n = 10). The establishment of consensus among the participants that an indicator reflected preventable drug-related morbidity in primary care. After preliminary validation, 37 of the original 57 US indicators were retained. The Delphi panel generated 16 additional new indicators in the first round. At the end of the second round, the pre-defined level of consensus was reached for 29 indicators (19 of the US generated indicators; 10 generated by the panel in the first round). The Delphi results highlighted differences in both the clinical perspective and, possibly, philosophical viewpoints of health professionals practising in the UK and US health care systems. Further work, located in both primary and secondary care, is now in progress to operationalize the indicators. This process will form a key part of the refining, and hence further validation, of the indicators. The future development of prospective medical-record-based indicators should facilitate a reduction in the human, clinical, and economic burden of drug-related morbidity.