A team approach to optimising medication outcomes in primary care
thesisposted on 28.02.2017 by Tan, Edwin Chin Kang
In order to distinguish essays and pre-prints from academic theses, we have a separate category. These are often much longer text based documents than a paper.
Background: Practice pharmacists often work in general and family practice clinics overseas, undertaking a variety of roles aimed at improving quality use of medicines by staff and patients. In Australia, the presence of pharmacists within general practice is uncommon and collaboration between general practitioners (GPs) and pharmacists in primary care remains low. There is currently limited Australian research evaluating the practice pharmacist role and stakeholder experiences with these services. Given that medication-related problems (MRPs) continue to be of concern in Australia, and quality use of medicines has been identified as an important quality indicator in general practice, the integration of pharmacists into Australian general practice warrants further investigation. The overall aim of the PhD project was to develop and evaluate the role of a practice pharmacist within Australian general practice. Methods: Firstly, a systematic review and meta-analyses of randomised controlled trials was undertaken to evaluate the effectiveness of pharmacist services delivered in general practice clinics on a variety of outcomes. Secondly, semi-structured interviews with a purposive sample of GPs and pharmacists was undertaken to explore their views on the integration of pharmacists into the general practice setting. Thirdly, a prospective, before-after study (the Pharmacists in Practice Study [PIPS]) was conducted at two primary healthcare clinics in Melbourne, Australia. The intervention consisted of a multi-faceted, collaborative service involving a part-time practice pharmacist co-located in each of the study clinics for six months. The practice pharmacists provided long and short patient consultations, drug information and education services, and quality improvement activities (a drug use evaluation [DUE] program for osteoporosis management). The main outcome measures were MRPs, medication adherence, quality of prescribing osteoporosis medicines, and experiences of staff and patients (explored both quantitatively and qualitatively using surveys, interviews, focus groups and narrative reports). Key findings: The systematic review included 38 studies, and found that pharmacists co-located in general practice clinics delivered a variety of interventions, with favourable results seen in certain areas of chronic disease management and quality use of medicines. Seventeen studies were included in meta-analyses and found significant reductions in systolic blood pressure (-5.72 mmHg [95% CI, -7.05 to -4.39, p<0.001]), diastolic blood pressure (-3.47 mmHg [95% CI, -4.35 to -2.58, p<0.001]), glycosylated haemoglobin (-0.88% [95% CI, -1.15 to -0.62, p<0.001]), LDL-cholesterol (-18.72 mg/dL [95% CI, -34.10 to -3.36, p<0.017]), total cholesterol (-32.00 mg/dL [95% CI, -54.86 to -9.14, p<0.006]) and Framingham cardiovascular risk score (-1.83% [95% CI, -3.66 to 0.00, p=0.05]) following pharmacist intervention. A total of 11 GPs and 16 pharmacists took part in the stakeholder interviews. The interviews revealed that although there was a positive professional relationship between GPs and pharmacists, there were limitations to the delivery of collaborative services. Various roles and methods of integration for pharmacists in general practice were identified, and it was suggested that these roles could offer both advantages and disadvantages; however, a number of barriers and facilitators to integration would need to be considered to ensure viability of services. In the PIPS, 82 patients received a long patient consultation and 62 (75.6%) were followed up over six months. After six months, the median number of MRPs fell from 2 (IQR 1, 4) to 0 (IQR 0, 1), p<0.001. The proportion of patients who were adherent to their medicines improved significantly, according to both the Morisky (44.1% versus 62.7%, p=0.023) and the TABS (35.6% versus 57.6%, p=0.019) scales. Patients were highly satisfied with the consultations, with 80.6% reporting they would like to have a pharmacist available in the clinic in the future. Twenty-five short patient consultations were undertaken, the majority of which addressed patient education (48.0%) and provided medication profiles (32.0%). The pharmacists documented 12 drug information queries and delivered four education sessions to staff. A total of 225 patients with a diagnosis of osteoporosis at baseline and 240 at the post-intervention audit 12 months later were part of the DUE program. The proportion of patients without documented contraindications to osteoporosis therapies who were prescribed an anti-osteoporosis medicine increased significantly from baseline at 12 months (134/225 [58.7%] vs. 168/240 [70.0%], p=0.002). Thirty-four participants were recruited to provide feedback on pharmacy services: 18 patients, 14 practice staff (9 GPs, 4 practice nurses, 1 practice manager), and two practice pharmacists. Five main themes emerged: environment; professional relationships and integration; pharmacist attributes; staff and patient benefits; and logistical challenges. Staff and patients were generally positive about the clinical pharmacy services. Conclusions: This project demonstrated the feasibility and value of pharmacist roles in optimising medication use in Australian primary healthcare clinics, and their acceptability by stakeholders. These findings will guide further research in this area.
Awards: Winner of the Mollie Holman Doctoral Medal for Excellence, Faculty of Art, Design and Architecture, .