Better outcomes for the patient, the provider and the society now: this is not a dream, and the pharmacist could help!
Geoff Watts reported in the BMJ that "failure to make full use of the knowledge of pharmacists has long been one of the profession’s recurrent preoccupations, regardless the awareness of the role that pharmacists could have—and in some cases already do—in the management of chronic health problems such as obesity, smoking, and asthma". A recent publication in BMC Health Services1 can offer a concrete example that community pharmacists do hold a pivotal role in asthma care beyond medicine dispensing and their contribution adds value to health service delivery in terms of improved clinical effectiveness, medicines adherence, quality of life, but also cost effectiveness for the NHS and the society overall.
Results from one of the largest trials in pharmacy practice in terms of numbers of pharmacists and asthmatic patients, suggest that the Italian Medicines Use Review (I-MUR) service provided by community pharmacists to asthmatic patients is more effective and cost effective than usual care, supporting its implementation in national practice (see box).
Is the profession allowed to say that pharmacists have a role in community care beyond dispensing and we can make full use of their knowledge and skills? The authors say yes, and believe that pharmacy-based patient-centred and clinically-oriented services like I-MUR could confirm that the pharmacists are important players within the team of healthcare professionals and they score well in health service delivery.
1 Manfrin A, Tinelli M, Thomas T, Krska J. A cluster randomised control trial to evaluate the effectiveness and cost-effectiveness of the Italian Medicines Use Review (I-MUR) for asthma patients. BMC Health Services Research 2017. DOI: 10.1186/s12913-017-2245-9
Box: Key features of the Italian medicines use review (I-MUR)
1- The innovation: the Italian medicines use review (I-MUR) service.
I-MUR service consists of a structured and systematic interview conducted in a private area of the pharmacy that focuses on five different dimensions: asthma symptoms; medicines used; attitude towards medicines; the extent to which patients take medicines as prescribed by their doctor (adherence); and identification of pharmaceutical care issues (PCIs).
2- Its evaluation: the I-MUR trial.
The I-MR trial involved 283 pharmacists and 1263 patients from 15 different regions of Italy. The purpose of the study was to assess whether I-MUR service is:
- Effective - Is it able to improve asthma control (when asthma symptoms are well managed), optimise the number of medicines used, identify and resolve issues related to the use of medicines, and increase the adherence to medicines (compared with usual care provided by the community pharmacist)? Does its effectiveness vary over time? Increase, decrease or remain stable?
- Cost-effective - Is asthma control accompanied by an improvement of quality of life and a decrease in costs (for the health care system and society overall)? What is the probability of being cost- effective? Does the cost -effectiveness vary over time?
3- The I-MUR service is effective and its effectiveness increased over time.
- Patients who received the I-MUR service showed a probability of achieving asthma control almost double (1.8) compared to those who did not receive after only 3 months. In addition, the positive effect of the I-MUR service increased over time; the percentage of increase in controlled patients was overall 42% at 9 months.
- The I-MUR service enabled to optimise the number of medicines used by patients (reduced by 8%). The median number of medicines taken by the patients before I-MUR was 5, and decreased to 4 after 3 months; this value remained constant over time (at six month follow-up).
- In 65% of cases, during the I-MUR consultation the pharmacists were able to identify key issues related to medicines utilisation, including: lack of patient education, lack of monitoring, possible discrepancy between prescribed and real dose taken.
- The patient adherence to therapy increased by 35% after 3 months and increased further reaching 40% at 6 and 9 months after the intervention. The more the patients followed their asthma treatment the more their asthma was controlled. Furthermore, clear link was identified between adherence to treatment and asthma control.
4- The I-MUR service is cost effective and cost saving. Its success increased over time.
The cost effectiveness analysis showed that I-MUR service is more cost-effective compared to usual service and it is accompanied by saving costs for the NHS sector and the society overall (from 3 months onward) and increased quality of life (from 6 months onward). The probability of being cost-effective doubled from 50% at 3 months to 100% at 9 months.
5- Its implementation.
This study demonstrates that the I-MUR service, which is the first cognitive pharmaceutical service to be delivered in Italy, was both effective and cost-effective. The Italian Government and Ministry of Health have since promoted a change of community pharmacy practice, with the I-MUR being the first nationally funded cognitive pharmaceutical service in Italy. The work has supported a significant cultural shift in Italian community pharmacy practice, from a mainly logistic to a more patient-centred and clinically-oriented role of the community pharmacist in delivery of health care.
Competing interests: No competing interests