Int J Clin Pharm (2014) 36:702–706 DOI 10.1007/s11096-014-9962-5
SHORT RESEARCH REPORT
Drug-related problems identified by pharmacists conducting medication use reviews at a primary health center in Qatar Nadir Kheir • Ahmed Awaisu • Amal Sharfi Maha Kida • Abdullah Adam
•
Received: 1 August 2013 / Accepted: 20 May 2014 / Published online: 26 June 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background Medication use review (MUR) is increasingly being recognized globally as a routine strategy performed by pharmacists to optimize the therapeutic outcomes of long-term medications. MUR services are not commonly available in hospitals and primary health care (PHC) centers in Qatar and no previous studies have reported the nature and extent of such services where they exist. Objective To describe the extent and types of drugrelated problems (DRPs) generated from MUR interactions conducted at a PHC facility in Qatar and to determine the effect of patient characteristics on the number of DRPs. Method This was a cross-sectional, descriptive and exploratory study. Data were generated and documented prospectively via semi-private interviews conducted by intervention pharmacists (n = 6). DRPs identified were categorized according to the Pharmaceutical Care Network of Europe DRP classification system. Results In 56 medication reviews conducted, a total of 173 DRPs were identified with an average of 3.3 DRPs per patient. The most commonly encountered DRPs were non-adherence (31 %), need for education (23 %), and adverse drug reactions (21 %). Patients receiving six or more medications had significantly higher number of DRPs compared to those receiving three medications (p B 0.05). Furthermore,
elderly patients tended to have more DRPs compared to younger patients and there was a linear relationship between age and DRPs. Conclusion This study shows that patients receiving polypharmacy and the elderly in Qatar are vulnerable to experiencing DRPs, many of which are potentially preventable through MURs. Keywords Drug-related problems DRPs Medication review Medication utilization review MUR Pharmacy Qatar
Impact of findings on practice •
•
Pharmacy leaders and policymakers in Qatar should determine the potential to integrate MUR on large scales in health care facilities in Qatar as part of the National Health Strategy. Pharmacy managers in primary health care (PHC) facilities and hospitals should stimulate MUR as a strategy that improves medication safety, reduce cost of illness, and improve the overall quality of life of patients with chronic illnesses.
Introduction N. Kheir (&) A. Awaisu A. Sharfi M. Kida College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar e-mail: [email protected] A. Adam Pharmacy Department, Medical Services, Qatar Petroleum, Doha, Qatar
123
A World Health Organization (WHO) report suggests that only about 50 % of patients on long-term therapies for chronic illnesses adhere to treatment recommendations [1]. Medication Use Review (MUR) provided by pharmacists has long been recognized as an adherence support strategy and the benefits of such service is increasingly being recognized worldwide as a routine part of helping patients
Int J Clin Pharm (2014) 36:702–706
adhere to prescribed medications and optimizing the outcomes of drug therapy [2]. MUR involves a pharmacist undertaking a private consultation with the patient, aiming to improve the patient’s knowledge, concordance and to detect any potential or actual drug-related problems (DRPs). A total of 8,000 community pharmacies in England reported involvement in MUR services and received reimbursements for the services; and between 2011 and 2012, over 2 million MURs were conducted at an estimated cost of £68 million [3, 4]. MUR services provided by pharmacists have also been reported from several other countries including Australia, Canada, the Netherlands, New Zealand, and the United States. Evidence suggests that medication reviews minimize the incidence of DRPs and ultimately optimize therapeutic outcomes [5]. A retrospective, cross-sectional case notes analysis of an MUR service provided by pharmacists in an aged-care facility has documented a reduction in potential side-effects (45 %), symptoms control (32 %), and an increase in drug efficacy (19 %) [6]. About 70 % of the pharmacists’ recommendations in these analyses were reported to be implemented by the resident medical practitioners. A systematic review revealed that the majority of MUR interventions were delivered in primary care settings and a single pharmacist to deliver the intervention has been used in 16 trials [7]. Qatar aims for a comprehensive world-class healthcare system whose services are accessible to the whole population. One of the cardinal goals and the main focus of the Qatar’s National Health Strategy 2011–2016 is to promote PHC that encompasses advanced pharmacy services such as MUR. Although MUR services had been introduced in a few health care facilities in the country, to our knowledge, no study that investigates the nature and extent of MUR services provided by pharmacists in Qatar and the types of DRPs identified had been published.
Aim of the study This exploratory descriptive study aims at characterizing the DRPs generated from MUR interactions conducted at a PHC facility in Qatar and determining the effects of patients’ characteristics on the number of DRPs. The primary outcome measure for this preliminary study was the types and number of DRPs captured by the pharmacists during the MURs.
Ethical approval The study was granted ethics approval by the Qatar University Institutional Review Board (QU-IRB 162-E/12).
703
Method Study design and setting This cross-sectional, descriptive, and exploratory study was conducted within a PHC facility in Qatar between 1 October and 31 December 2012. Data collection tool An MUR form to capture relevant data from the MUR interactions was adapted from the Medication Review Form developed by one of the United Kingdom’s National Health Services (NHS) primary care trusts, Cumbria [8] supplemented by literature review. The final form contained three main sections: (1) patients’ demographic and clinical characteristics; (2) detailed information related to each of the drugs taken by the patient including adherence and side-effects and; (3) any DRPs detected and interventions made by the pharmacists (including education provided, referral made, dosage modified, medicine discontinued, and any other interventions). However, for the purpose of this study, we will report only DRPs identified and their classification. Details of any intervention conducted is beyond the scope of the project. Inclusion criteria For a patient to be enrolled in the study, s/he must be over 18 years of age, on a minimum of three medications taken concurrently, and must provide consent. Data collection procedures For consistency purposes, the pilot pharmacists (n = 6) were provided with an orientation session on study requirements including definitions, classification of DRPs, and the documentation processes, prior to data collection. The data collection process involved identifying and contacting patients who were eligible for inclusion in the MUR, explaining the purpose of the study, and obtaining their consent to participate. The pharmacist agreed with the patient on a specific date and time to conduct a review. On the day of the review, the patient brought all their medications and met the pharmacist in a private consultation area within the clinic where the pharmacist conducted a consultation session and collected the required information. Pharmacists used the MUR forms to document the interactions with the patients, generated the data prospectively, then submitted the filled forms to the research team after being reviewed by a study coordinator at the PHC facility for consistency purposes. Two members of the research team (AS and MK) categorized the interventions as per the
123
704
Int J Clin Pharm (2014) 36:702–706
Table 1 Categories and frequencies of drug-related problems identified in an MUR service
Table 2 Influence of medications and disease characteristics on the prevalence of DRPs
DRP category
Frequency (%)
Characteristics
P3.2—drug without indication
11 (6.2)
Gender
Mean ± SD
p value
0.133*
P1.4—untreated indication
4 (2.3)
Male
2.93 ± 2.64
C1.4—duplicate therapy
5 (2.9)
Female
4.82 ± 3.40
C1.1—contraindication
2 (1.1)
P1.1—ineffective drug
4 (2.3)
18–29
0±0
C3.1—dose too low
13 (7.4)
30–49
3.14 ± 2.64
C3.2—high dose C1.3—drug interaction
3 (1.7) 1 (0.6)
50–64 65 and above
3.46 ± 2.95 4.20 ± 2.96
C1.1—inappropriate drug
1 (0.6)
P2.1—adverse drug reaction
36 (20.6)
3
1.56 ± 1.42
C2.1—inappropriate form
1 (0.6)
4
3 ± 2.56
0.052
C7—poor adherence
54 (30.9)
5
3.29 ± 2.84
0.035§
C6
4.86 ± 3.39
I2.1—need for education
Age (in years)
Number of medications
40 (22.9) Total DRPs = 175
Type of disease(s) Diabetes alone
Pharmaceutical Care Network of Europe (PCNE) classification of DRPs [9]. The classification has four primary domains for problems, eight primary domains for causes and five primary domains for Interventions. For the purpose of this study, we adopted the PCNE’s definition of a DRP’’… as an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes’’ [9]. Data analysis The data collected were analyzed using SPSS software (version 19.0) and presented as frequencies, means and standard deviation (SD) as appropriate. Independent t test, One way ANOVA, and post hoc analysis using Tukey’s HSD were applied in order to determine the influence of the patient-related and medication-related characteristics on the number of DRPs identified.
Results Fifty-two eligible patients were reviewed by the six pilot pharmacists in this study. The majority of the participants (79 %) were male, around 46 % were in the age group of 50–64 years, while 10 % were 65 years and above. Many of the patients (40 %) were diagnosed with concurrent diabetes, hypertension, and dyslipidemia and more than half of them were receiving at least five medications concomitantly. Overall, a total of 175 DRPs were identified with an average of 3.4 DRPs per patient (Table 1). The most commonly reported DRPs were: non-adherence to drug
123
0.60
2.67 ± 1.16
Diabetes ? Dyslipidemia
6 ± 1.41
Hypertension ? Dyslipidemia
5 ± 4.39
Diabetes ? Hypertension ? Dyslipidemia
3.05 ± 3.23
Others
2.85 ± 2.32
0.227
* Independent student t test was applied
one way ANOVA test was applied
§
post hoc analysis using of Tukey’s HDS was applied
therapy (31 %), need for education and counseling (23 %), and adverse drug reactions (21 %). Table 2 represents the influence of patient-related, medication-related, and disease-related characteristics on the incidence of DRPs detected. Notably, female patients tended to have more DRPs than male patients, but this did not reach statistical significance (4.8 ± 3.4 vs. 2.9 ± 2.6 DRPs; p = 0.133). As would be expected, there was a strong association between the incidence of DRPs and the patients’ age; as the age increases, the number of DRPs consistently increases. Furthermore, there appears to be a positive linear relationship between the number of medications prescribed and the incidence of DRPs identified [i.e. as the number of medications increased, the number of the identified DRPs tended to increase (p B 0.05)]. A post hoc analysis using Tukey’s HSD revealed that patients taking six or more medications had significantly higher number DRPs compared with those receiving three medications (p B 0.05). However, no evidence of association or consistent pattern was observed between concurrent medical conditions and the number of DRPs. A finding that was noteworthy was a patient on three concurrent diuretics and two other antihypertensive medicines from the same class that necessitated a pharmacist’s
Int J Clin Pharm (2014) 36:702–706
urgent intervention (an urgent written and documented referral was made after cautioning the patient of the concurrent administration). Furthermore, a number of patients had clear indications for preventative therapy with aspirin.
Discussion The current study highlights and explores the feasibility of establishing an MUR service at a primary care setting from the context of a developing nation that is witnessing both a remarkable advancement in pharmacy practice and transformation of its entire healthcare delivery system. This service provides an opportunity for an extended professional role of a pharmacist; this is in complete alignment with the Qatar’s National Health Strategy which aims to develop a world-class PHC system that emulates best practices around the world. Polypharmacy and irrational use of drug therapy are increasingly becoming major issues of concern among patients with chronic diseases, particularly the elderly and those having multiple comorbidities. This study further documents the extent of DRPs among patients on multiple medications. These DRPs would have been missed without a systematic process such as MUR. The potential consequences of unidentified DRPs could vary, but would undoubtedly result in poor health outcomes and the potential for repeated unwarranted clinic and hospital visits. The current study found that patients taking more than six medications had a significantly higher number of DRPs compared to patients receiving only three medications. In a hospital-based study, the investigators reported that the risk of experiencing DRPs increased linearly with the number of medication on admission, a finding that is similar to the current study [10]. Furthermore, a medication review in Netherland showed that the number of drugs used and age were significantly correlated with the number of DRPs, which is also consistent with our findings [11]. Our cohort of pharmacists included individuals with varying degrees of experiences with MUR service provision, but all work within a PHC service that encourages the implementation of the service and promotes it through its inclusion within the pharmacy strategic plans and as one of the key performance indicators. None of the pharmacists who conducted these reviews underwent any specialized MUR training or credentialing, but the majority of them hold graduate diplomas in clinical pharmacy and/or are regular attendees of continuing professional pharmacy development programs. A MUR service in some jurisdiction should involve accredited pharmacists undertaking the structured adherence-centered reviews with patients on multiple medicines, particularly those receiving medicines for long-term conditions in a private consultation area
705
within the pharmacy [2]. However, one could argue that generalist pharmacists are capable of identifying DRPs and making interventions that improve drug use process, although we have no data to support this hypothesis. We advocate that pharmacists providing this service should receive sufficient training, patients need to be made more aware of the expected benefits of a structured MUR program, and time has to be dedicated for the pharmacist to provide effective and high quality MUR service. An important limitation of this study was the small sample size which might have reduced the potential for achieving statistical significance in some of the outcomes measured. The study did not document the consequences of the pharmacists’ MUR interventions (i.e. the overall clinical outcomes of the MURs). Further studies should investigate the clinical outcomes of MUR interventions in order to provide the evidence of benefits of such services in primary care settings.
Conclusion The study findings suggest that pharmacists practicing in primary care settings in Qatar are capable of providing MUR services to selected patients with chronic medical conditions and that pharmacists with clinical training and adequate job support will be able to identify DRPs through the implementation of MUR service. Finally, the current findings have important implications on practice, particularly pertaining to the implementation of MUR service as an extended role of pharmacists and as part of the National Health Strategy agenda to move PHC forward in Qatar. Acknowledgments The authors would like to thank all pharmacists who provided the MUR services and the patients who participated in the study. Funding Funding was received from Qatar University under the Undergraduate Research Fund. Conflicts of interest
None to declare.
References 1. Sabate´ E. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003. 2. Pharmaceutical Services Negotiating Committee. Medicines use review (MUR): the medicines use review and prescription intervention service [Online]. 2013 [cited 25 July 2013]; available from: http://psnc.org.uk/services-commissioning/advancedservices/murs/). [Cited 25 Jul 2013]. 3. Latif A, Pollock K, Boardman HF. Medicines use reviews: a potential resource or lost opportunity for general practice? BMC Fam Pract. 2013;14:57. 4. Brossoie N, Roberto KA, Barrow KM. Making sense of intimate partner violence in late life: comments from online news readers. Gerontologist. 2012;52(6):792–801.
123
706 5. Finkers F, Maring JG, Boersma F, Taxis K. A study of medication reviews to identify drug-related problems of polypharmacy patients in the Dutch nursing home setting. J Clin Pharm Ther. 2007;32(5):469–76. 6. Khalil H. A review of pharmacist recommendations in an aged care facility. Aust J Prim Health. 2011;17(1):35–9. 7. Latif A, Pollock K, Boardman HF. The contribution of the Medicines Use Review (MUR) consultation to counseling practice in community pharmacies. Patient Educ Couns. 2011;83(3): 336–44. 8. NHS. Clinical Medication Review [Online]. 2013 [cited 2013 Jul 1]. Available from: http://www.cumbria.nhs.uk/ProfessionalZone/ MedicinesManagement/Guidelines/MedicationReview-Practice Guide2011.pdf.
123
Int J Clin Pharm (2014) 36:702–706 9. The PCNE DRP classification [Online]. 2010 [cited 2011 Apr 28]. Available from: http://www.pcne.org/sig/drp/drug-relatedproblems.php. 10. Viktil KK, Blix HS, Moger TA, Reikvam A. Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clin Pharmacol. 2007;63(2):187–95. 11. Kempen T, Gompel C, Hoogland D, Bouvy LM. Drug related problems and interventions recorded in the Service Apotheek Medication Review Tool [Online]. 2013 [cited 30 Jul 2013]. Available from: http://vkc.library.uu.nl/vkc/upper/Lists/Events/ DispForm.aspx?ID=186&ContentTypeId=0x01001C88203559E F0545BBF6EBEF79014029.
SHORT RESEARCH REPORT
Drug-related problems identified by pharmacists conducting medication use reviews at a primary health center in Qatar Nadir Kheir • Ahmed Awaisu • Amal Sharfi Maha Kida • Abdullah Adam
•
Received: 1 August 2013 / Accepted: 20 May 2014 / Published online: 26 June 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background Medication use review (MUR) is increasingly being recognized globally as a routine strategy performed by pharmacists to optimize the therapeutic outcomes of long-term medications. MUR services are not commonly available in hospitals and primary health care (PHC) centers in Qatar and no previous studies have reported the nature and extent of such services where they exist. Objective To describe the extent and types of drugrelated problems (DRPs) generated from MUR interactions conducted at a PHC facility in Qatar and to determine the effect of patient characteristics on the number of DRPs. Method This was a cross-sectional, descriptive and exploratory study. Data were generated and documented prospectively via semi-private interviews conducted by intervention pharmacists (n = 6). DRPs identified were categorized according to the Pharmaceutical Care Network of Europe DRP classification system. Results In 56 medication reviews conducted, a total of 173 DRPs were identified with an average of 3.3 DRPs per patient. The most commonly encountered DRPs were non-adherence (31 %), need for education (23 %), and adverse drug reactions (21 %). Patients receiving six or more medications had significantly higher number of DRPs compared to those receiving three medications (p B 0.05). Furthermore,
elderly patients tended to have more DRPs compared to younger patients and there was a linear relationship between age and DRPs. Conclusion This study shows that patients receiving polypharmacy and the elderly in Qatar are vulnerable to experiencing DRPs, many of which are potentially preventable through MURs. Keywords Drug-related problems DRPs Medication review Medication utilization review MUR Pharmacy Qatar
Impact of findings on practice •
•
Pharmacy leaders and policymakers in Qatar should determine the potential to integrate MUR on large scales in health care facilities in Qatar as part of the National Health Strategy. Pharmacy managers in primary health care (PHC) facilities and hospitals should stimulate MUR as a strategy that improves medication safety, reduce cost of illness, and improve the overall quality of life of patients with chronic illnesses.
Introduction N. Kheir (&) A. Awaisu A. Sharfi M. Kida College of Pharmacy, Qatar University, P.O. Box 2713, Doha, Qatar e-mail: [email protected] A. Adam Pharmacy Department, Medical Services, Qatar Petroleum, Doha, Qatar
123
A World Health Organization (WHO) report suggests that only about 50 % of patients on long-term therapies for chronic illnesses adhere to treatment recommendations [1]. Medication Use Review (MUR) provided by pharmacists has long been recognized as an adherence support strategy and the benefits of such service is increasingly being recognized worldwide as a routine part of helping patients
Int J Clin Pharm (2014) 36:702–706
adhere to prescribed medications and optimizing the outcomes of drug therapy [2]. MUR involves a pharmacist undertaking a private consultation with the patient, aiming to improve the patient’s knowledge, concordance and to detect any potential or actual drug-related problems (DRPs). A total of 8,000 community pharmacies in England reported involvement in MUR services and received reimbursements for the services; and between 2011 and 2012, over 2 million MURs were conducted at an estimated cost of £68 million [3, 4]. MUR services provided by pharmacists have also been reported from several other countries including Australia, Canada, the Netherlands, New Zealand, and the United States. Evidence suggests that medication reviews minimize the incidence of DRPs and ultimately optimize therapeutic outcomes [5]. A retrospective, cross-sectional case notes analysis of an MUR service provided by pharmacists in an aged-care facility has documented a reduction in potential side-effects (45 %), symptoms control (32 %), and an increase in drug efficacy (19 %) [6]. About 70 % of the pharmacists’ recommendations in these analyses were reported to be implemented by the resident medical practitioners. A systematic review revealed that the majority of MUR interventions were delivered in primary care settings and a single pharmacist to deliver the intervention has been used in 16 trials [7]. Qatar aims for a comprehensive world-class healthcare system whose services are accessible to the whole population. One of the cardinal goals and the main focus of the Qatar’s National Health Strategy 2011–2016 is to promote PHC that encompasses advanced pharmacy services such as MUR. Although MUR services had been introduced in a few health care facilities in the country, to our knowledge, no study that investigates the nature and extent of MUR services provided by pharmacists in Qatar and the types of DRPs identified had been published.
Aim of the study This exploratory descriptive study aims at characterizing the DRPs generated from MUR interactions conducted at a PHC facility in Qatar and determining the effects of patients’ characteristics on the number of DRPs. The primary outcome measure for this preliminary study was the types and number of DRPs captured by the pharmacists during the MURs.
Ethical approval The study was granted ethics approval by the Qatar University Institutional Review Board (QU-IRB 162-E/12).
703
Method Study design and setting This cross-sectional, descriptive, and exploratory study was conducted within a PHC facility in Qatar between 1 October and 31 December 2012. Data collection tool An MUR form to capture relevant data from the MUR interactions was adapted from the Medication Review Form developed by one of the United Kingdom’s National Health Services (NHS) primary care trusts, Cumbria [8] supplemented by literature review. The final form contained three main sections: (1) patients’ demographic and clinical characteristics; (2) detailed information related to each of the drugs taken by the patient including adherence and side-effects and; (3) any DRPs detected and interventions made by the pharmacists (including education provided, referral made, dosage modified, medicine discontinued, and any other interventions). However, for the purpose of this study, we will report only DRPs identified and their classification. Details of any intervention conducted is beyond the scope of the project. Inclusion criteria For a patient to be enrolled in the study, s/he must be over 18 years of age, on a minimum of three medications taken concurrently, and must provide consent. Data collection procedures For consistency purposes, the pilot pharmacists (n = 6) were provided with an orientation session on study requirements including definitions, classification of DRPs, and the documentation processes, prior to data collection. The data collection process involved identifying and contacting patients who were eligible for inclusion in the MUR, explaining the purpose of the study, and obtaining their consent to participate. The pharmacist agreed with the patient on a specific date and time to conduct a review. On the day of the review, the patient brought all their medications and met the pharmacist in a private consultation area within the clinic where the pharmacist conducted a consultation session and collected the required information. Pharmacists used the MUR forms to document the interactions with the patients, generated the data prospectively, then submitted the filled forms to the research team after being reviewed by a study coordinator at the PHC facility for consistency purposes. Two members of the research team (AS and MK) categorized the interventions as per the
123
704
Int J Clin Pharm (2014) 36:702–706
Table 1 Categories and frequencies of drug-related problems identified in an MUR service
Table 2 Influence of medications and disease characteristics on the prevalence of DRPs
DRP category
Frequency (%)
Characteristics
P3.2—drug without indication
11 (6.2)
Gender
Mean ± SD
p value
0.133*
P1.4—untreated indication
4 (2.3)
Male
2.93 ± 2.64
C1.4—duplicate therapy
5 (2.9)
Female
4.82 ± 3.40
C1.1—contraindication
2 (1.1)
P1.1—ineffective drug
4 (2.3)
18–29
0±0
C3.1—dose too low
13 (7.4)
30–49
3.14 ± 2.64
C3.2—high dose C1.3—drug interaction
3 (1.7) 1 (0.6)
50–64 65 and above
3.46 ± 2.95 4.20 ± 2.96
C1.1—inappropriate drug
1 (0.6)
P2.1—adverse drug reaction
36 (20.6)
3
1.56 ± 1.42
C2.1—inappropriate form
1 (0.6)
4
3 ± 2.56
0.052
C7—poor adherence
54 (30.9)
5
3.29 ± 2.84
0.035§
C6
4.86 ± 3.39
I2.1—need for education
Age (in years)
Number of medications
40 (22.9) Total DRPs = 175
Type of disease(s) Diabetes alone
Pharmaceutical Care Network of Europe (PCNE) classification of DRPs [9]. The classification has four primary domains for problems, eight primary domains for causes and five primary domains for Interventions. For the purpose of this study, we adopted the PCNE’s definition of a DRP’’… as an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes’’ [9]. Data analysis The data collected were analyzed using SPSS software (version 19.0) and presented as frequencies, means and standard deviation (SD) as appropriate. Independent t test, One way ANOVA, and post hoc analysis using Tukey’s HSD were applied in order to determine the influence of the patient-related and medication-related characteristics on the number of DRPs identified.
Results Fifty-two eligible patients were reviewed by the six pilot pharmacists in this study. The majority of the participants (79 %) were male, around 46 % were in the age group of 50–64 years, while 10 % were 65 years and above. Many of the patients (40 %) were diagnosed with concurrent diabetes, hypertension, and dyslipidemia and more than half of them were receiving at least five medications concomitantly. Overall, a total of 175 DRPs were identified with an average of 3.4 DRPs per patient (Table 1). The most commonly reported DRPs were: non-adherence to drug
123
0.60
2.67 ± 1.16
Diabetes ? Dyslipidemia
6 ± 1.41
Hypertension ? Dyslipidemia
5 ± 4.39
Diabetes ? Hypertension ? Dyslipidemia
3.05 ± 3.23
Others
2.85 ± 2.32
0.227
* Independent student t test was applied
one way ANOVA test was applied
§
post hoc analysis using of Tukey’s HDS was applied
therapy (31 %), need for education and counseling (23 %), and adverse drug reactions (21 %). Table 2 represents the influence of patient-related, medication-related, and disease-related characteristics on the incidence of DRPs detected. Notably, female patients tended to have more DRPs than male patients, but this did not reach statistical significance (4.8 ± 3.4 vs. 2.9 ± 2.6 DRPs; p = 0.133). As would be expected, there was a strong association between the incidence of DRPs and the patients’ age; as the age increases, the number of DRPs consistently increases. Furthermore, there appears to be a positive linear relationship between the number of medications prescribed and the incidence of DRPs identified [i.e. as the number of medications increased, the number of the identified DRPs tended to increase (p B 0.05)]. A post hoc analysis using Tukey’s HSD revealed that patients taking six or more medications had significantly higher number DRPs compared with those receiving three medications (p B 0.05). However, no evidence of association or consistent pattern was observed between concurrent medical conditions and the number of DRPs. A finding that was noteworthy was a patient on three concurrent diuretics and two other antihypertensive medicines from the same class that necessitated a pharmacist’s
Int J Clin Pharm (2014) 36:702–706
urgent intervention (an urgent written and documented referral was made after cautioning the patient of the concurrent administration). Furthermore, a number of patients had clear indications for preventative therapy with aspirin.
Discussion The current study highlights and explores the feasibility of establishing an MUR service at a primary care setting from the context of a developing nation that is witnessing both a remarkable advancement in pharmacy practice and transformation of its entire healthcare delivery system. This service provides an opportunity for an extended professional role of a pharmacist; this is in complete alignment with the Qatar’s National Health Strategy which aims to develop a world-class PHC system that emulates best practices around the world. Polypharmacy and irrational use of drug therapy are increasingly becoming major issues of concern among patients with chronic diseases, particularly the elderly and those having multiple comorbidities. This study further documents the extent of DRPs among patients on multiple medications. These DRPs would have been missed without a systematic process such as MUR. The potential consequences of unidentified DRPs could vary, but would undoubtedly result in poor health outcomes and the potential for repeated unwarranted clinic and hospital visits. The current study found that patients taking more than six medications had a significantly higher number of DRPs compared to patients receiving only three medications. In a hospital-based study, the investigators reported that the risk of experiencing DRPs increased linearly with the number of medication on admission, a finding that is similar to the current study [10]. Furthermore, a medication review in Netherland showed that the number of drugs used and age were significantly correlated with the number of DRPs, which is also consistent with our findings [11]. Our cohort of pharmacists included individuals with varying degrees of experiences with MUR service provision, but all work within a PHC service that encourages the implementation of the service and promotes it through its inclusion within the pharmacy strategic plans and as one of the key performance indicators. None of the pharmacists who conducted these reviews underwent any specialized MUR training or credentialing, but the majority of them hold graduate diplomas in clinical pharmacy and/or are regular attendees of continuing professional pharmacy development programs. A MUR service in some jurisdiction should involve accredited pharmacists undertaking the structured adherence-centered reviews with patients on multiple medicines, particularly those receiving medicines for long-term conditions in a private consultation area
705
within the pharmacy [2]. However, one could argue that generalist pharmacists are capable of identifying DRPs and making interventions that improve drug use process, although we have no data to support this hypothesis. We advocate that pharmacists providing this service should receive sufficient training, patients need to be made more aware of the expected benefits of a structured MUR program, and time has to be dedicated for the pharmacist to provide effective and high quality MUR service. An important limitation of this study was the small sample size which might have reduced the potential for achieving statistical significance in some of the outcomes measured. The study did not document the consequences of the pharmacists’ MUR interventions (i.e. the overall clinical outcomes of the MURs). Further studies should investigate the clinical outcomes of MUR interventions in order to provide the evidence of benefits of such services in primary care settings.
Conclusion The study findings suggest that pharmacists practicing in primary care settings in Qatar are capable of providing MUR services to selected patients with chronic medical conditions and that pharmacists with clinical training and adequate job support will be able to identify DRPs through the implementation of MUR service. Finally, the current findings have important implications on practice, particularly pertaining to the implementation of MUR service as an extended role of pharmacists and as part of the National Health Strategy agenda to move PHC forward in Qatar. Acknowledgments The authors would like to thank all pharmacists who provided the MUR services and the patients who participated in the study. Funding Funding was received from Qatar University under the Undergraduate Research Fund. Conflicts of interest
None to declare.
References 1. Sabate´ E. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003. 2. Pharmaceutical Services Negotiating Committee. Medicines use review (MUR): the medicines use review and prescription intervention service [Online]. 2013 [cited 25 July 2013]; available from: http://psnc.org.uk/services-commissioning/advancedservices/murs/). [Cited 25 Jul 2013]. 3. Latif A, Pollock K, Boardman HF. Medicines use reviews: a potential resource or lost opportunity for general practice? BMC Fam Pract. 2013;14:57. 4. Brossoie N, Roberto KA, Barrow KM. Making sense of intimate partner violence in late life: comments from online news readers. Gerontologist. 2012;52(6):792–801.
123
706 5. Finkers F, Maring JG, Boersma F, Taxis K. A study of medication reviews to identify drug-related problems of polypharmacy patients in the Dutch nursing home setting. J Clin Pharm Ther. 2007;32(5):469–76. 6. Khalil H. A review of pharmacist recommendations in an aged care facility. Aust J Prim Health. 2011;17(1):35–9. 7. Latif A, Pollock K, Boardman HF. The contribution of the Medicines Use Review (MUR) consultation to counseling practice in community pharmacies. Patient Educ Couns. 2011;83(3): 336–44. 8. NHS. Clinical Medication Review [Online]. 2013 [cited 2013 Jul 1]. Available from: http://www.cumbria.nhs.uk/ProfessionalZone/ MedicinesManagement/Guidelines/MedicationReview-Practice Guide2011.pdf.
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