We read with interest the report of the study by Holland and
colleagues, which showed that home-based medication review by pharmacists
increased the rate of readmission to hospital. Our experience, using a
hospital-based medication review as part of a randomised, controlled
evaluation of an integrated medicines management service, shows that
readmissions are reduced by 7.9% at 12 months.1
1. Holland and colleagues suggest that the intervention might have
increased adherence and thereby induced iatrogenic disease, although they
then dismiss the possibility as a previous study showed no improvements in
adherence. This, in itself, is curious because improved adherence was
presumably one of the principles on which the design of this study was
based. The risk of iatrogenic disease in this age group is serious and
warrants careful attention. A fundamental principal of pharmaceutical care
is that the prescribed medicines must be appropriate in the first place.
Medication appropriateness can be measured using the Medication
Appropriateness Index (MAI)2. An assessment of medication appropriateness
at the time of discharge from hospital or after the medication review,
might have offered more insight into the possibility of iatrogenic
illness. In our experience, medication reviews are associated with a
marked increase in MAI score.
2. It is difficult to understand how a meaningful or clinically-
relevant medication review can take place without access to the medical
record. Without this information the pharmacist undertaking the review and
offering advice on how to take the medications can do little more than
repeat the instructions on the labels. It is not possible to make an
assessment of the patient’s ability, preferences or medicine-taking
behaviour in their proper context. However, we disagree with this
suggestion that effective medication review can take place with the
medical record but without the patient. In our experience, meaningful
medication review can only occur when both the medical record and the
patient are present, in the context of an integrated service.
3. Our experience of training pharmacists to undertake effective
medication reviews suggests that pharmacists need significant experience
of clinical practice in order to do this competently. Although some post
–qualification education had been received by the participating
pharmacists, their level of clinical practice was not documented.. The
authors say that possible drug reactions and interactions were reported
to the GPs. It is not clear from this whether other medication-related
problems, which are often harbingers of medication-related morbidity, were
reported and neither is it clear what action the GPs took in response to
this information.
4. Professor Christine Bond, in her comments to the Pharmaceutical Journal
(29th January 2005)3 points out that there are many unknowns between the
intervention and outcome in this study. We concur with her comments and
also wish to suggest that some of the problems might have arisen from the
practice model on which this study was based i.e. a visiting pharmacist
who was not part of the regular service. We suggest that pharmaceutical
expertise could be used more effectively within the framework of a care
team, all members of which have access to a common medical record.
MG Scott PhD FPSNI MCPP Chief pharmacist, United Hospitals Trust,
Antrim
A Hogg BSc MPSNI Clinical Services Development Pharmacist, United
Hospitals Trust, Antrim
JC McElnay PhD FPSNI FACCP Dean of The Faculty of Science and
Agriculture,
The Queens University of Belfast
CM Clark PhD FRPharmS Principal Research Fellow in Clinical
Therapeutics (part-time), University of Bradford School of Pharmacy
References
1. Beagon P, Scott MG,McElnay JC. Quantifying the impact of an intensive
clinical pharmacy service on re-admission rates to hospital. Pharmacy
World and Science 2004; 26: A9
2. Hanlon JT ,Schmader KE, Samsa GP,Weinberger ,M, Utttech KM,lewis
IK et al. A method for assessing drug therapy appropriateness. J Clin
Epidemiol. 1992;45:1045-1051
3. Moberley T. Medication review hangs in the balance. Pharm J
2005;274:106
We read with interest the report of the study by Holland and
colleagues, which showed that home-based medication review by pharmacists
increased the rate of readmission to hospital. Our experience, using a
hospital-based medication review as part of a randomised, controlled
evaluation of an integrated medicines management service, shows that
readmissions are reduced by 7.9% at 12 months.1
1. Holland and colleagues suggest that the intervention might have
increased adherence and thereby induced iatrogenic disease, although they
then dismiss the possibility as a previous study showed no improvements in
adherence. This, in itself, is curious because improved adherence was
presumably one of the principles on which the design of this study was
based. The risk of iatrogenic disease in this age group is serious and
warrants careful attention. A fundamental principal of pharmaceutical care
is that the prescribed medicines must be appropriate in the first place.
Medication appropriateness can be measured using the Medication
Appropriateness Index (MAI)2. An assessment of medication appropriateness
at the time of discharge from hospital or after the medication review,
might have offered more insight into the possibility of iatrogenic
illness. In our experience, medication reviews are associated with a
marked increase in MAI score.
2. It is difficult to understand how a meaningful or clinically-
relevant medication review can take place without access to the medical
record. Without this information the pharmacist undertaking the review and
offering advice on how to take the medications can do little more than
repeat the instructions on the labels. It is not possible to make an
assessment of the patient’s ability, preferences or medicine-taking
behaviour in their proper context. However, we disagree with this
suggestion that effective medication review can take place with the
medical record but without the patient. In our experience, meaningful
medication review can only occur when both the medical record and the
patient are present, in the context of an integrated service.
3. Our experience of training pharmacists to undertake effective
medication reviews suggests that pharmacists need significant experience
of clinical practice in order to do this competently. Although some post
–qualification education had been received by the participating
pharmacists, their level of clinical practice was not documented.. The
authors say that possible drug reactions and interactions were reported
to the GPs. It is not clear from this whether other medication-related
problems, which are often harbingers of medication-related morbidity, were
reported and neither is it clear what action the GPs took in response to
this information.
4. Professor Christine Bond, in her comments to the Pharmaceutical Journal
(29th January 2005)3 points out that there are many unknowns between the
intervention and outcome in this study. We concur with her comments and
also wish to suggest that some of the problems might have arisen from the
practice model on which this study was based i.e. a visiting pharmacist
who was not part of the regular service. We suggest that pharmaceutical
expertise could be used more effectively within the framework of a care
team, all members of which have access to a common medical record.
MG Scott PhD FPSNI MCPP Chief pharmacist, United Hospitals Trust,
Antrim
A Hogg BSc MPSNI Clinical Services Development Pharmacist, United
Hospitals Trust, Antrim
JC McElnay PhD FPSNI FACCP Dean of The Faculty of Science and
Agriculture,
The Queens University of Belfast
CM Clark PhD FRPharmS Principal Research Fellow in Clinical
Therapeutics (part-time), University of Bradford School of Pharmacy
References
1. Beagon P, Scott MG,McElnay JC. Quantifying the impact of an intensive
clinical pharmacy service on re-admission rates to hospital. Pharmacy
World and Science 2004; 26: A9
2. Hanlon JT ,Schmader KE, Samsa GP,Weinberger ,M, Utttech KM,lewis
IK et al. A method for assessing drug therapy appropriateness. J Clin
Epidemiol. 1992;45:1045-1051
3. Moberley T. Medication review hangs in the balance. Pharm J
2005;274:106
Competing interests:
None declared
Competing interests: No competing interests