Pharmaceutical Care Model Research Articles

A Cluster Randomized Controlled Trial of an Adapted U.S. Model of Pharmaceutical Care for Nursing Home Residents in Northern Ireland (Fleetwood Northern Ireland Study): A Cost‐Effectiveness Analysis

To evaluate the cost-effectiveness of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood NI Study). Economic evaluation alongside a cluster randomized controlled trial. Nursing homes in NI randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11). Residents aged 65 and older who provided informed consent (N=253; 128 intervention, 125 control) and who had full resource use data at 12 months. Trained pharmacists reviewed intervention home residents' clinical and prescribing information for 12 months, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to make changes. The control homes received usual care in which there was no pharmacist intervention. The proportion of residents prescribed one or more inappropriate psychoactive medications (according to standardized protocols), costs, and a cost-effectiveness acceptability curve. The latter two outcomes are the focus for this article. The proportions of residents receiving inappropriate psychoactive medication at 12 months in the intervention and control group were 19.5% and 50.4%, respectively. The mean cost of healthcare resources used per resident per year was $4,923 (95% confidence interval (CI)=$4,206-5,640) for the intervention group and $5,053 (95% CI=$4,328-5,779) for the control group. The probability of the intervention being cost-effective was high, even at low levels of willingness to pay to avoid a resident receiving inappropriately prescribed psychoactive medication. The Fleetwood NI model of care was more cost-effective than usual care.

Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes

The objective of this study was to assess implementation of a pharmaceutical care model for the multidisciplinary care of elderly patients in nursing homes. Prospective study, medication review, from January 2007 to December 2009 in ten nursing homes affiliated to the Pharmacie interjurassienne (PIJ), Switzerland. Medication use data were collected and reviewed by a pharmacist, focusing on drug indication, dosing, side effects, renal/hepatic elimination and interactions. Drug-related problems (DRPs) were discussed face-to-face with the responsible physician and a nurse. The pharmaceutical care issues were formulated and medication interventions proposed during this meeting. DRPs and interventions were documented using the Pharmaceutical Care Network Europe scheme version 5.00 (PCNE V5.00). The economic impact of the service was estimated through a retrospective evaluation of annual drug costs. A satisfaction evaluation was conducted among practitioners and nurses. DRPs, interventions, treatment changes implemented. Drug therapy of 329 patients was reviewed. The number of medicines per patient ranged from 2 to 27 (mean 12.8). A total of 1,225 DRPs were detected and discussed with the physician and the nurse. Medication review led to 343 medical evaluations secondary to drug-drug interactions and 803 treatment adaptations: 373 drugs were stopped, 197 dosages changed, 95 instructions for use amended, 86 drug choices were altered, 35 drug formulations changed and 17 new drugs started. According to the Anatomical Classification System, the main classes involved in interventions were related to Alimentary tract and metabolism (n = 285), Nervous system (n = 189) and Cardiovascular system (n = 115). Since the outset of the PIJ, the annual drug costs decreased in nursing homes with medication review including a pharmacist, whereas it was stable in the other nursing homes. The satisfaction evaluation showed a very positive appreciation by practitioners and nurses. The study showed an efficient pharmaceutical care model, well accepted by physicians and nurses. It also indicated that for elderly patients, continuous drug review contributed to improved drug therapy, reduced unnecessary polypharmacy and reduced pharmaceutical costs.

Impact of a pharmaceutical care model for non-institutionalised elderly: results of a randomised, controlled trial

Abstract Objectives To measure the impact of a community-based geriatric pharmaceutical care model on specific process measures. Methods The model was evaluated using a prospective, randomised, controlled study design. Clients who self-presented or were referred by Home Care were eligible if they were 65 years of age or older, non-institutionalised, taking two or more prescribed or non-prescribed medications, and willing to provide signed informed consent. A pharmacist conducted a comprehensive drug therapy review on test clients, then addressed issues with the client and/or the client's physician, with follow-up as required. Measurements included number of drugs, drug knowledge, adherence to therapy, cost of prescribed medicines, and number of reported symptoms obtained from a home medication history conducted by trained volunteers, the provincial prescription claims database, and response to a physician survey. Setting The pharmaceutical care model was situated within a community-based interdisciplinary health clinic targeting non-institutionalised elderly. Key findings One hundred and thirty-five clients were randomised to test (n=69) or control (n=66). A mean of 14.4 (SD 4.6) potential or actual issues were identified in test clients. Ninety-four per cent of physicians agreed with at least one of the pharmacist's recommendations but only 230 of 794 recommendations by the pharmacist (29 per cent) resulted in a change. There was no difference in overall number of prescribed or over-the-counter medications, drug costs, symptoms reported, drug knowledge or medication adherence between test and control groups post-intervention. Future research Further research is needed to identify barriers to changing drug use behaviour and facilitating acceptance of pharmaceutical care in the community.

A community-based pharmaceutical care model for the elderly: report on a pilot project

Abstract This paper describes the development and pilot evaluation of a pharmacy consultation service for the elderly. The service is a comprehensive, community-based pharmaceutical care model which identifies drug-related problems in the elderly population. Eligible clients were 55+ years of age, taking two or more items of medication and non-institutionalised. The pharmaceutical care model involved home medication histories, drug therapy review, and consultation with physicians and individual clients. The service was evaluated through therapeutic outcomes monitoring, follow-up interviews with clients and questionnaires mailed to physicians. The 20 pilot clients had a mean age of 77 ± 7 years. They took a mean of 8.6 ±3.7 prescription drugs and 9.2 ± 7.9 non-prescription drugs. Potential and actual problems identified which could have adversely affected desired therapeutic outcomes included adverse drug reactions, untreated indications, suboptimal regimens, and improper drug selection. Sixteen of the 20 pilot clients participated in follow-up interviews. A reduction in the number of non-current labels was the only statistically significant difference noted between baseline and follow-up interviews. However, changes consistent with pharmacy recommendations were noted for almost all other drug-related problems identified. Questionnaires relating to 16 clients were completed by 15 physicians. Although the physicians agreed with 79 per cent of the recommendations, only 31 per cent of recommendations resulted in a change to the drug regimen. The majority of physicians surveyed rated the service as somewhat useful to very useful. The need for pharmaceutical review in this population is demonstrated by the number of drug-related problems identified. Although the model led to numerous positive outcomes, further research is required to evaluate the effectiveness of this proposed strategy.

Identification of the pharmaceutical needs of patients with heart failure

Abstract Focal points

Developing and evaluating a model for pharmaceutical care in Australian community pharmacies

Abstract Objective To develop and evaluate a medication management service. The service was based on the principles of pharmaceutical care and targeted patients at risk of medication misadventure, primarily elderly patients, in five community pharmacies. Methods In phase one, pharmacists defined the service in consultation with consumers, medical practitioners and professional pharmacy organisations. Agreed characteristics of the service were: patient selection criteria, a structured patient care process, systematic documentation, a quality assurance process and a complementary relationship with services of other health professionals. Implementation and evaluation of the service occurred in the second phase. The service was provided over an 11-month period to 205 patients. Key findings Of the patients who received the service, 179 (87 per cent) had one or more medication or health-related problems. Pharmacists identified a total of 526 problems. Follow-up was available for 432 problems and 75 per cent of these problems were well managed by the end of the study. Of the 115 consumers surveyed, 74 responded. Eighty-five per cent of respondents believed the service had made a “significant” or “great” contribution to their health and 64 per cent thought that their knowledge of their medication had improved. Health economic evaluation indicated that net cost benefits were delivered to the health system. The net annual cost savings per patient ranged from $A40 to $A311. Conclusion Pharmacists were able to apply the principles of pharmaceutical care to meet the needs of at-risk consumers in the community. Further development of this service delivery model is under way and would appear to offer substantial advantages to consumers and the health system.

Pharmaceutical care: cultural, practice and professional perspectives

AbstractFocal points

Implementation of the Fleetwood model of pharmaceutical care in nursing homes: impact on the long-term care pharmacy team

Implementation of the Fleetwood model of pharmaceutical care in nursing homes: impact on the long-term care pharmacy team

A consensus model for delivery of structured pharmaceutical care for the patient with type 2 diabetes mellitus by Scottish community pharmacists

AbstractObjectiveTo generate a model of pharmaceutical care for the patient with type 2 diabetes mellitus in primary care, from a consensus determined among community pharmacists in Scotland. Setting Community pharmacists within Scotland already involved in providing structured pharmaceutical care.MethodThe Delphi questionnaire was based on a validated multidisciplinary model of care for the patient with type 2 diabetes mellitus in primary care comprising 47 items under five themes: assessment, treatment plan, treatment administration, patient monitoring, confirmation/review. Seventy participants already participating in a pharmaceutical care model schemes initiative to encourage pharmaceutical care from community pharmacies and with an interest in diabetes mellitus were sent an initial questionnaire. Thirty-seven participants agreed to enter two further rounds; response rates were 22/37 (59%) and 18/22 (82%). Final round cut-off defining consensus was 80% scoring 6–7 from a seven-point Likert scale.Key findingsA model emerged from the achieved consensus. There was an early consensus achieved on the core functions that participants were already delivering to the patient with diabetes mellitus. These are functions that have been highlighted and delivered in previous studies within this disease state: receiving and sharing patient information, individualising treatment, identifying unsatisfactory treatment and monitoring and prescribing analgesia.ConclusionsFor service development and linked continued professional development a well-defined service model for delivering pharmaceutical care to patients is required. This study proposes such a model based on consensus among a self-selected group of community pharmacists leading diabetes pharmacy practice in Scotland.

An Evaluation of an Adapted U.S. Model of Pharmaceutical Care to Improve Psychoactive Prescribing for Nursing Home Residents in Northern Ireland (Fleetwood Northern Ireland Study)

To test the effect of an adapted U.S. model of pharmaceutical care on prescribing of inappropriate psychoactive (anxiolytic, hypnotic, and antipsychotic) medications and falls in nursing homes for older people in Northern Ireland (NI). Cluster randomized controlled trial. Nursing homes randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11). Residents aged 65 and older who provided informed consent (N=334; 173 intervention, 161 control). Specially trained pharmacists visited intervention homes monthly for 12 months and reviewed residents' clinical and prescribing information, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to improve the prescribing of these drugs. The control homes received usual care. The primary end point was the proportion of residents prescribed one or more inappropriate psychoactive medicine according to standardized protocols; falls were evaluated using routinely collected falls data mandated by the regulatory body for nursing homes in NI. The proportion of residents taking inappropriate psychoactive medications at 12 months in the intervention homes (25/128, 19.5%) was much lower than in the control homes (62/124, 50.0%) (odds ratio=0.26, 95% confidence interval=0.14-0.49) after adjustment for clustering within homes. No differences were observed at 12 months in the falls rate between the intervention and control groups. Marked reductions in inappropriate psychoactive medication prescribing in residents resulted from pharmacist review of targeted medications, but there was no effect on falls.

Effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings.

The pharmaceutical care approach serves as a model for medication review, involving collaboration between GPs, pharmacists, patients, and carers. Its use is advocated with older patients who are typically prescribed several drugs. However, it has yet to be thoroughly evaluated. To estimate the effectiveness of pharmaceutical care for older people, shared between GPs and community pharmacists in the UK, relative to usual care. Multiple interrupted time-series design in five primary care trusts which implemented pharmaceutical care at 2-month intervals in random order. Patients acted as their own controls, and were followed over 3 years including their 12 months' participation in pharmaceutical care. In 2002, 760 patients, aged > or =75 years, were recruited from 24 general practices in East and North Yorkshire. Sixty-two community pharmacies also took part. A total of 551 participants completed the study. Pharmaceutical care was undertaken by community pharmacists who interviewed patients, developed and implemented pharmaceutical care plans together with patients' GPs, and thereafter undertook monthly medication reviews. Pharmacists and GPs attended training before the intervention. Outcome measures were the UK Medication Appropriateness Index, the Short Form-36 Health Survey (SF-36), and serious adverse events. The intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes. Although the mental component of the SF-36 decreased as study participants become older, this trend was not affected by pharmaceutical care. The RESPECT model of pharmaceutical care (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) shared between community pharmacists and GPs did not significantly change the appropriateness of prescribing or quality of life in older patients.

Cost-effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings

Pharmaceutical care serves as a collaborative model for medication review. Its use is advocated for older patients, although its cost-effectiveness is unknown. Although the accompanying article on clinical effectiveness from the RESPECT (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) trial finds no statistically significant impact on prescribing for older patients undergoing pharmaceutical care, economic evaluations are based on an estimation, rather than hypothesis testing. To evaluate the cost-effectiveness of pharmaceutical care for older people compared with usual care, according to National Institute for Health and Clinical Excellence (NICE) reference case standards. An economic evaluation was undertaken in which NICE reference case standards were applied to data collected in the RESPECT trial. On average, pharmaceutical care is estimated to cost an incremental 10 000 UK pounds per additional quality-adjusted life year (QALY). If the NHS's cost-effectiveness threshold is between 20 000 and 30 000 UK pounds per extra QALY, then the results indicate that pharmaceutical care is cost-effective despite a lack of statistical significance to this effect. However, the statistical uncertainty surrounding the estimates implies that the probability that pharmaceutical care is not cost-effective lies between 0.22 and 0.19. Although results are not sensitive to assumptions about costs, they differ between subgroups: in patients aged >75 years pharmaceutical care appears more cost-effective for those who are younger or on fewer repeat medications. Although pharmaceutical care is estimated to be cost-effective in the UK, the results are uncertain and further research into its long-term benefits may be worthwhile.

ESCP 37th European Symposium on Clinical Pharmacy, Pharmaceutical Care Models, and Therapeutic Innovations, Dubrovnik, Croatia, 21–24 October 2008

ESCP 37th European Symposium on Clinical Pharmacy, Pharmaceutical Care Models, and Therapeutic Innovations, Dubrovnik, Croatia, 21–24 October 2008

Assessment of a pharmaceutical interventional programme in patients on medications with renal risk

ObjectiveTo compare the adaptation of medical prescriptions according to the dosage guides in patients with renal disease, before and after applying a pharmaceutical intervention programme. The secondary objectives were to prepare a guide to dosing in renal disease and to measure the prevalence of prescription of drugs with renal risk. MethodNon-randomised, experimental interventional study (before/after) conducted in a general hospital with 800 beds, including hospitalised patients, over the age of 18, with kidney disease and drugs with renal risk prescribed in their pharmaco-therapeutic profile. The study was designed to be carried out in 2 descriptive cross-cutting phases (control group) and a prospective interventional cohort study (intervention group). The primary variable was the percentage non-adaptation according to the stage of renal disease. ResultsThe study included 185 patients, 88 in the control group and 97 in the intervention group. In the intervention group, the prevalence of non-compliance before and after the intervention was 18.7% and 2.1%, representing a statistically significant reduction in nonadaptation of the dose. The costs saved with the pharmaceutical intervention programme were 1939.63 euro over 2 months, the average saving per medication intervened amounting to 62.57 euro (95% CI, 23.99–101.14 euro; P=.02). ConclusionsThe results of the study indicate that the application of a pharmaceutical care model based on the prospective validation of drugs with renal risk, very significantly improved the adaptation of dosing regimens in kidney disease.

Évaluation des besoins pharmacothérapeutiques d’un service de pédopsychiatrie

Objective To develop a structured and reproducible approach to evaluate pharmaceutherapeutic needs. The approach should allow a pharmacist task description on the unit in order to optimize pharmaceutical care. Patients and methods Descriptive study of pharmaceutical care model. The selected unit is a pediatric psychiatry unit in Sainte-Justine hospital, a teaching hospital of 500 beds. The methodology includes a literature review conducted to describe the impact of clinical pharmacist on selected health indicators; a profile of patients and clinical activities; a description of pharmacotherapy needs and an update of task description. Results Studies demonstrate that pharmacists have an impact on selected clinical outcomes following clinical pharmacy activities: drug therapy monitoring, intervention to improve compliance, and education. Health indicators revealed that patients admitted in the pediatric psychiatry unit have a better prognosis than average patients in the hospital, but a longer length of stay (23.4 days versus 5.8 days). For pharmacy services, their drug cost per admission is 50 $ per admission (children) and 183 $ per admission (adolescents) versus 380 $ for all the patients treated at CHU Sainte-Justine. The approach helped us to identify interventions to manage outpatients, to provide medication history and clinical tools to reduce prescription error. Conclusion This is the first study to illustrate an approach for the evaluation of a pharmacotherapeutic needs in a pediatric psychiatry unit.

Have We Fulfilled the Opportunity Crafted by Our Governance Task Force

J C P H – Vol. 61, n 1 – janvier–fevrier 2008 92 Council that will remain relevant for many years: customer service culture, alignment of products and services with mission, data-driven strategies, dialogue and engagement, the CEO as a broker of ideas, organizational adaptability, and alliance-building. In more clinical terms, these elements might be called patient centricity, alignment of medication therapy with outcome plans, use of evidence in clinical decisions, inclusion of the patient in the clinical team’s discussions, clinical leaders as the sources of ideas to achieve desired outcomes, adaptability to best meet the patient’s needs, and, finally, alliance-building, including the clinical elements and infrastructure needed to ensure desired patient outcomes. My suggested alignment of the administrative elements of a successful board with the more familiar clinical services delivery model of pharmaceutical care may be somewhat loose. However, these two layers of activity are critically important not just to the evolution of the practice of pharmacy, but also to our Society’s efforts to represent the collective interests of pharmacists during the revolution of our place in the interprofessional care of patients. The CSHP Council now has this additional set of lenses through which to view its continuous growth, and the members who follow in our footsteps in the years ahead will be better able to achieve in full our Society’s mission.

Effect of pharmaceutical care services on outcomes for home care patients with heart failure

The effect of pharmaceutical care services for home care patients with heart failure on death and rehospitalization rates was studied. Eligible patients had to be at least 21 years old and included those with a primary or secondary diagnosis of heart failure who were referred to receive skilled nursing services. Patients were then randomized to receive usual care or pharmaceutical care. Patients assigned to the usual care group received the services typically provided by the visiting nurses association, while patients in the pharmaceutical care group received usual care plus standardized services from a clinical pharmacist. Pharmaceutical care services consisted of an initial comprehensive in home medication assessment and two follow-up visits. Throughout the three-week intervention period, the clinical pharmacist accessed and reviewed all pertinent physician notes and laboratory test values and interacted with prescribers on behalf of the patients as necessary. A total of 154 patients met all criteria and participated in the study. The pharmacist made 79 specific therapy recommendations, 47 (60%) of which were related directly to drug therapy for heart failure or cardiovascular disease. Overall, 14 therapy recommendations were fully implemented, and 10 heart failure-specific recommendations were fully implemented. Patients for whom the pharmacist had made recommendations that were followed by the prescriber had a reduced rate of the composite primary endpoint, but this difference did not reach statistical significance. A home-based pharmaceutical care model for recently hospitalized patients with heart failure did not significantly improve the combined rate of death or rehospitalization.

A New Vision for Pharmacy Education: It Is Time to Shift the Old Paradigm and Move Forward

A New Vision for Pharmacy Education: It Is Time to Shift the Old Paradigm and Move Forward

Assessment of a United States pharmaceutical care model for nursing homes in the United Kingdom

To assess the suitability of an American model of pharmaceutical care for nursing home residents (The Fleetwood model) for application in nursing homes in the United Kingdom. Pharmacists (those from a hospital setting or involved in prescribing support), general practitioners, nursing home managers and advocates for older people were invited to participate in semi-structured interviews or focus groups. The American Fleetwood model was explained to all participants who were asked for their views and opinions on how such a model could be adapted for use in the UK setting. All interviews and focus groups were tape-recorded, transcribed verbatim and analysed using the framework method. An adapted model of pharmaceutical care for use in UK nursing homes. There was general concern about prescribing in nursing homes, particularly in relation to psychoactive drugs. All participants were supportive of the proposed model of care and endorsed the greater involvement of pharmacists. However, participants also recognised that unlike pharmacists in the US nursing home setting for which the Fleetwood model had been developed, pharmacists implementing this approach in the UK would face major challenges in relation to access to records (medical and medication), prescribers and residents. The findings highlighted the key elements of access which will need to be considered if this model of pharmaceutical care is to be applied to nursing home residents in the UK. IMPACT OF FINDINGS ON PRACTICE: The model has been revised to take account of the challenges relating to access and will be tested in a randomised controlled trial.

Étude pilote sur la mise en place des soins pharmaceutiques dans le service de pédiatrie générale d'un hôpital français. Collaboration et comparaison franco-québécoise

State of the problem and objectives French pharmacists are quasi absent from hospital wards. Our objective was to describe the implantation of pharmaceutical care in a patient unit of a French paediatric hospital. Material and methods Following an internship in pharmaceutical care at the Sainte-Justine hospital (SJ) in Montreal, a French pharmacist returned to France to implement the pharmaceutical model in a paediatric unit at Robert Debré hospital (RD) in Paris. We first collected pharmaceutical interventions carried out during a 5-month period. In a second phase, we compared pharmaceutical interventions provided by the team composed of the same French pharmacist and a pharmacist from Québec in both settings during 14 days respectively. Results In the first phase, 556 interventions were done (8.2 ± 2,0 per day) with a significant increase observed during the first 2 months. In the second phase, 216 interventions were done at RD and 174 at SJ. The interventions were mainly related to drug information, modification of treatment and seamless care with the pharmacy of the hospital or a community pharmacy. The interventions targeted junior (30.5 to 55.4%), senior physicians (16.2 to 38.5%) and pharmacy (11.5 to 16.2%) in the different phases and sites. A high level of physician acceptance was observed, with respectively 86.0 and 93.1% at RD and SJ. Discussion French pharmacists can apply the pharmaceutical care model following a specific training. Further studies are required to evaluate the feasibility and the impact of pharmaceutical care in France.