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Rapid Responses: Rapid Responses published:
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Evidence of lack of consultation skills is not evidence that pharmacists cannot do clinical medication reviews
- Duncan R Petty, Arnold Zermansky (30 April 2007)
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Making medication reviews work for patients
- Nina L Barnett, Derek Taylor, UK Clinical Pharmacy Association, Care of the Elderly Practice Interest Group, Catherine Bowyer, Senior Pharmacist for Elderly Care and NSF, Southampton University Hospitals Trust (3 May 2007)
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Comment on BMJ article HeartMed randomised controlled trial
- Carlene D Smith, Jenny Blennerhassett (7 May 2007)
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Difficult to generalise?
- Magnus I Hird (26 May 2007)
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Duncan R Petty, Lecturer Practitioner University of Leeds, LS2 9UT, Arnold Zermansky
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Salter et al (1)identify some deficiencies in a small sample of pharmacist consultations. We think they (perhaps involuntarily) set themselves up to fail in this study. Their results say more about the need for consultation skills training and the context of the pharmacists and patients involved in this study than they do about the concept of pharmacist medication review. The pharmacists involved in this study were the wrong people with the wrong skills and the wrong tools doing the wrong job at the wrong time. They were the wrong people because they had no connection with the patient, the general practitioner, the local pharmacy or the hospital department and therefore lacked credibility. They had the wrong skills because they scrupulously avoided exploring patient ideas and beliefs and persisted in a predetermined agenda that patients did not identify with. They had the wrong tools because they did not have the medical records or any indication for the medicines. They were doing the wrong job because people who have just had their medicines reviewed are not likely to benefit from a further review. And the timing was wrong because older people just discharged from the turmoil of hospital need some time to settle and reflect before intervening again. We feel this study says little about pharmacist ability to conduct medication reviews. The HOMER study (2) was not a realistic model for pharmacist medication review. The discharge note must be reviewed in context of the clinical record and in discussion with the GP. Only then should the patient be visited. Their paper is therefore a lesson in the need to construct a useful intervention before setting out to test it. It is also reminds us of the need to learn Osler’s century old lesson “Listen to the patient, he’s telling you the diagnosis”. Reference 1. Salter C, Holland R, Harvey R, Henwood K. "I haven't even phoned my doctor yet." The advice giving role of the pharmacist during consultations for medication review with patients aged 80 or more: qualitative discourse analysis BMJ, Apr 2007; doi:10.1136/bmj.39171.577106.55 2. Holland R, Lenaghan E, Harvey I, Smith R, Shepstone L, Lipp A, Christou M, Evans D, and Hand C. Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial BMJ, Feb 2005; 330: 293 Competing interests: None declared |
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Nina L Barnett, Consultant Pharmacist, London, Eastern and South East Specialist Pharmacy Services Pharmacy, Northwick Park Hospital, Watford Road, Harrow HA1 3UJ, Derek Taylor, UK Clinical Pharmacy Association, Care of the Elderly Practice Interest Group, Catherine Bowyer, Senior Pharmacist for Elderly Care and NSF, Southampton University Hospitals Trust
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The authors of this paper suggest that the advice-giving role of pharmacists during consultations with patients aged 80 or more has the potential to undermine and threaten the patients’ assumed competence, integrity and self-governance. While the study highlights the need for pharmacists to improve their consultation skills in the situations described, there are a number of other points to consider when interpreting this work. The patient population The trial was based on a small sub-analysis of 29/758 patients from the HOMER trial (1). As these patients were selected from a previous trial population, we do not know if the patients in this trial knew the results of the HOMER trial and no details of the time between HOMER and this trial were given. No details of patient selection criteria, other than Mental Test Score (MTS) and previous hospital admission, are given, nor are details of patients’ requirement for medication review provided in the study. The reviews The reviews are reported as ‘clinical medication reviews’ without any further clarification or reference to any standard definition. We are aware of a number of different types of medication review which require different background information and have a variety of uses. There are no details of how the medication reviews were performed, whether they patient led, scripted, conducted using forms/guidelines. This is likely to have affected the patient’s ability and desire to ask questions during the review. The study does not state any objectives for the review undertaken, bringing into question the value of the reviews without stated objectives. The reviewers The reviewers were stated to be pharmacists with at least 15 years experience as community pharmacists. However, there is no mention of how much experience in home based face to face medication review. In the study, these the reviewers were involved in a 2 day course and were required to have postgraduate qualifications or Continuing Professional Developement (CPD) in therapeutics. We suggest that the skills required for home-based medication review need regular and frequent use to lead to competent practice and it is unclear whether this is the case for the study pharmacists. Pharmacists were said to have used a didactic method in consultations, which supports the likelihood that their experience was community pharmacy based, where this method is required to transmit information in a concise, time-efficient manner, but is not the method of choice for medication review. Communication There is no evidence that the patient’s primary health care provider (assumed to be the General Practitioner) communicated with the patient regarding these medication reviews, nor communicated with the pharmacist to include them in the health care team. The pharmacists in the study had no existing relationship with the patients nor were they part of the patient's existing health care team, which does not reflect common practice. In summary, there is nothing to suggest that the patients in the study either wanted or needed a medication review. The method of medication review used in this study does not reflect the practice situation. Current good practice, based on evidence (2), suggests that successful interventions with patients occur when pharmacists are part of the primary health care team: where GPs and pharmacists are overtly working together for patient benefit and where the patient wants help with their medicines. We suggest that familiarity and trust between the pharmacist and the patient is important in the success of medication reviews, particularly in an older population. We agree that pharmacists may have been perceived to be in competition with the patients’ doctors regarding medicines and this reinforces our view that medication reviews must be undertaken as part of the multidisciplinary health care team. We highlight that some statements in the study can be interpreted in a variety of ways. For example, the statement relating to a patient who says that he will start taking his cod liver oil as “soon as the doctor says I can”, does not appear to us as either a rejection or rebuttal of pharmacist advice, rather a statement of faith in the doctor which is to be expected, particularly in a patient population of this age. We note that, according to the transcript, the pharmacist had not offered any advice in this situation. Conclusions The transcripts from this study describe the effect of isolated medication reviews by pharmacists who were unknown to the patient. The pharmacists appear to have had little background knowledge of the patient’s medication history and the reviews were conducted outside the health care team. In addition, the reviews were not requested by the patients and in light of these facts, the patients’ comments are unsurprising. We recognise that this paper has lessons for pharmacists. These include raising the issue of appropriate training for home based medication reviews and questioning the value of a single, isolated medication review undertaken without the prior involvement of the patient and their regular primary health care team. However, we do not feel that authors’ conclusions are justified from the evidence presented. The transcripts presented do indeed demonstrate the didactic nature of the pharmacists’ reviews and raises questions about the appropriateness of this method, but the authors have not presented evidence to demonstrate that this has undermined or potentially undermined the ‘assumed competency integrity or self governance’ of that patient in their medicines management. We suggest that if this study took place in a setting where the pharmacist was known to the patient, had the support of the GP and worked as part of the health care team to conduct medication reviews, we might see a markedly different set of results. References 1. Holland R et al. Does medication review keep older people out of hospital? The HOMER randomised controlled trial. BMJ 2005;330:293 2. Zermansky A et al., Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice. BMJ, Dec 2001; 323: 1340 Competing interests: None declared |
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Carlene D Smith, Pharmacist St Leonards 2065, Jenny Blennerhassett
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BMJ, doi:10.1136/bmj.39171.577106.55 (published 20 April 2007) http://www.bmj.com/cgi/rapidpdf/bmj.39171.577106.55v1 This is a complex area to examine and conflicting results from many studies indicate that the findings from this study are open to further examination. Following are our comments on this article: There is no information on other disease states for either intervention or control patients. People with CHF usually have several co-morbidities. Therefore, the intervention and control groups are not matched for co- morbidities that could influence re-admission rates. Several studies have shown that demographic characteristics, medical history and co-morbidity are correlated with early re-admission in patients with CHF. There will be intervening variables in the 2 groups after discharge, dependent on co- morbidity, which may account for a re-admission. "Total emergency admissions" is a crude outcome measure. There is no information on what the admissions were for. Were they related to heart failure? Were they related to other disease states? Would have been better to measure "avoidable admissions". It's crucial to know what the re- admission is for--in current CHF programs, there is re-admission differentiation, so that the statistics can reflect effectiveness of post- discharge CHF intervention. This study excluded patients with KNOWN planned admissions, but did not differentiate between planned and unplanned in the re-admission data. Some re-admissions may be appropriate and necessary--this is not measured in the study. Luthi et al published a paper called "Readmission to hospital an indicator of poor process of care for patients with heart failure?" in the Quality and Safety Health Care Journal 2004;13:46-51. They state that there is conflict about the validity of re-admission as a quality indicator--early re-admission is sometimes interpreted as a problem following discharge, due to inadequate care during the hospital stay, but other factors occurring after discharge may contribute to re-admission. They state that there's a lack of valid risk adjustment methods and that it is important to understand the limitations of outcome measurements. It is not known from this study what wards the study patients were recruited from aged care, cardiology, general medical, respiratory or renal and therefore, what impact the care differences during admission may have had on discharge and management after discharge. Living alone as a category is not always helpful as the patient may not be living alone, but may have no effective support at home. There's a baseline comparison for ¡§living alone¡¨ and 'using drug adherence aid', - noted that the intervention group has a higher number using an adherence aid--this may signify that there's more people with cognitive impairment in the intervention group. This may affect readmission, mortality and QOL. It is not stated whether patients managed their medications or whether the medications were managed by a carer. This may impact on adherence. There is no information on other medicines these patients were taking, particularly NSAIDs or COX-2 Inhibitors, which can exacerbate CHF and cause avoidable admissions to hospital. Interestingly, there were more patients on ACEI, spironolactone and digoxin in the intervention group- this may indicate the patients in the intervention group were not as well controlled. Primary care data was collected on a subgroup of trial patients, specifically from practices containing more than 3 trial patients--it is unknown whether exclusion of patients from some practices (how many?) may have influenced the results. Whilst it is noted that patients from residential facilities were excluded, there is no indication of how many patients were admitted into long term care in both groups during the study. McAlister et al in a paper titled "systematic review of randomised trials of disease management programs in heart failure" Am J Med 2001; 110: 378-84, warn that "carve-out" disease management programs may fragment care sufficiently, that patients with other conditions may be overlooked, therefore it is even more important to have medication review by pharmacists (as evidenced in your paper -half the recommendations were about non-cardiac medications/conditions) Education and information to general practitioners was not mentioned in this study. It is unknown whether discharge information to general practitioners was standard for all patients in the study or whether guidance on up-titration of ACEI and beta-blockers, for example, was included. Several studies have examined specialist generalist models and Blennerhasset et al in a paper "Novel Medicines Management Pathway" in JPPR 2006;36, describe a process of provision of clinical information from the hospital setting and education, by a liaison pharmacist to accredited community pharmacists, for medication review of CHF patients post- discharge. Improved communication by this process facilitated the collaborative Home Medicines Review service and promoted long-term monitoring by community pharmacists. More studies are required using this type of model. There is now a trend in Australia for CHF, COPD, diabetes, etc to be included in total chronic disease programs involving hospital and community health professionals using specialist-generalist models, to reduce fragmentation, duplication or omission of care. Carlene Smith
Jenny Blennerhassett Pharmacist for Community Health Services, Prince of Wales Hospital Community Liaison Pharmacist for the Heartlink Program Barker St, Randwick 2031 Jenny.Blennerhassett@SESIAHS.HEALTH.NSW.GOV.AU Competing interests: None declared |
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Magnus I Hird, Pharmacist Practitioner Bloomfield Medical Centre, Blackpool, FY1 6JW
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I read with interest the findings of Salter et al (1) in their qualitative analysis of medication reviews conducted by pharmacists and agree that a common sense idea should not be exempted the rigorous testing required of less intuitive interventions. However I wonder whether the necessary specifics of the research preclude meaningful generalisation to large parts of everyday practice. Some of the points already raised by Petty and Zermansky in an earlier Rapid Response are crucially important, notably the lack of a prior relationship between patient and pharmacist which would likely preclude the comfort and trust necessary in a therapeutic relationship, and the didactic approach taken which emphasises issues with skills and training. Yet there are several other important factors at play in this situation that may impact on the outcomes and how these apply to the wider patient population. Perhaps the most influential of these is the patient's perceptions of the role of the pharmacist at the outset. The beliefs and attitudes of an over-80 group are not necessariy the same as all others and many readers will surely have heard the numerous variants on "but you're not the doctor" spoken by patients. Without completely falling into a stereotype these more often come from older individuals then younger, reflecting changing attitudes in society. Along with this often comes the belief that you cannot question the doctor and that "the doctor knows best". Indeed the transcripts and quotes used in Salter's paper highlight this very issue perfectly. These feelings would therefore make it very likely that advice would either be ignored as it hasn't come from a doctor, or disregarded as to adopt it would necessitate challenging the doctor's perceived authority. So by selecting this population the outcome that emerged may not be completely unexpected. Improved consultation skills and abilities to actively engage patients in decision making where they wish to be are fundamentally important for all healthcare professionals and will only become more so. That this applies to pharmacists too should be no surprise and to hope to remedy it with a small section on a 2-day training course is a fallacy. However there is clearly a need for helping patients with their medicines in an appropriate manner and context: the recent National Audit Office report citing £100 million in wasted medicines alone serves to highlight this, as does the large number of (generally accepted) interventions made by pharmacists to already well reviewed medication regimes in Holland et al's paper (2) also in this issue. So perhaps it would be premature and unhelpful to write off this role of pharmacists based on these findings? 1. Salter C, Holland R, Harvey R, Henwood K. "I haven't even phoned my doctor yet." The advice giving role of the pharmacist during consultations for medication review with patients aged 80 or more: qualitative discourse analysis BMJ, Apr 2007; doi:10.1136/bmj.39171.577106.55 2. Holland R, Brooksby I, Lenaghan E, Ashton K, Hay L, Smith R, et al. Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial. BMJ 2007 doi: 10.1136/bmj. 39164.568183.AE Competing interests: I am a pharmacist working within a general practice |
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