Impacts on practice

  • Patients have views about their experience of polypharmacy medication review clinics which they can voice through a questionnaire.

  • The patient feedback about medication reviews in the UK supports a shift towards employing clinical pharmacists within GP practices.

Introduction

‘The prescribing of multiple medicines inappropriately, or where the intended benefit of the medicines are not realised’ is known as problematic polypharmacy [1]. Polypharmacy can decrease medication adherence and increase the incidence of adverse drug reactions (ADRs) and drug–drug interactions, resulting in falls, hospitalisations and other complications especially in the elderly [2]. Medication-related problems of polypharmacy can be prevented through patient-centred medication reviews [1]. There is some evidence that pharmacist-led polypharmacy services for older people reduce inappropriate prescribing internationally [3]. However, there is a perception that the majority of research in this area has been completed without examining patients’ viewpoints [1]. One qualitative study conducted with patients to gather views about pharmacist-run medication review clinics in general practice found wide-ranging views that were themed by the authors according to patient perceptions before the reviews and then their experiences of attending [4].

Patient involvement in decisions about medication use is fundamental in polypharmacy. For example, there is conflicting evidence on patients’ willingness to accept prescriber decisions to de-prescribe [5] and doctors worry about patients’ unwillingness to stop longstanding medications [6]. Patient feedback about polypharmacy medication reviews is arguably a key indicator of the success of such services. Alongside this, the NHS in England has been working with the Royal Pharmaceutical Society (RPS) on a 3-year pilot to test the role of clinical pharmacists within general practice (GP) surgeries [7]. There is a gap in the literature in relation to outcomes associated with pharmacist-led medication reviews conducted within GP practices in England, specifically patients’ perception of such services.

Aim of the study

The aim of this study was to investigate patient views about a patient-centred clinical pharmacist-led polypharmacy medication review service completed within GP practices with those ≥ 75 years of age and prescribed ≥ 15 medications.

Ethics approval

Ethical approval was granted by the University’s Research Ethics procedures (School of Food, Chemistry and Pharmacy Ethics Review Committee) in January 2016.

Methods

The patient-centred pharmacist-led polypharmacy medication review service

There were 819 patients (0.39–2.99% of patients registered with each practice) who were ≥ 75 years of age and prescribed ≥ 15 medications (excluding palliative care cases and those in registered care homes) in the 34 GP practices in Windsor, Ascot & Maidenhead (in south east England); more than half (56%) were female. The highest percentage of patients taking ≥ 15 medicines was in the 70–79 year old age band (28%). All 819 patients were invited via a letter to a pharmacist-led medication review at GP practices in Windsor, Ascot & Maidenhead between April 2015 and March 2016.

Reviews were completed by one of four pharmacist independent prescribers employed by Clinical Commissioning Groups (CCGs) as prescribing support clinical pharmacists. The reviews drew on the principles of patient-centred care, medicines optimisation in polypharmacy [1], and other good-practice guidelines [8] with direct access to the medical record and in discussion with the patient. Medication changes were enacted directly on electronic systems by the pharmacist independent prescribers. The main intervention element was prescription changes as well as patient education and signposting. A record of all changes and recommendations, reasons for changes and projected annual cost savings were made contemporaneously and are described below.

A total of 415 consultations (with 415 different patients) were completed (51% attendance rate) in 17 GP practices, resulting in a total of 901 medication-related changes. The changes involved stopping a medication, adding a medication, decreasing a dose, and increasing a dose. The reasons for changes were documented and categorised as relating to prescribing quality (improving clinical management or preventing harm from the medication), patient reported side-effects and formulary recommendations. Some example and reasons for common changes made included stopping an anticholinergic to reduce the risk of adverse drug reactions; starting medication for prevention of osteoporotic fractures; adjusting the dose or time of furosemide to reduce adverse drug reactions; up titration of ACE inhibitor dose in heart failure to reduce morbidity. Pharmacists also signposted patients to other services such as a falls clinic or talking therapies. A net saving of around £37,000 per annum (£90/patient) was predicted based on the prescribing changes, with − £46,000 as cost savings and + £9000 as additional spends on medication.

Data collection and analysis

A patient feedback questionnaire was constructed and face validated with two pharmacists then posted by a CCG pharmacist to all patients who had taken part in the service within 3 months of attending. CCGs are clinically-led health bodies responsible for the planning and commissioning of health care services for local areas in England. There are 209 CCGs in England and this study covered three CCGs. Data from returned questionnaires were transferred to SPSS (v21) and analysed using descriptive statistics. Qualitative patient comments were analysed using thematic analysis meaning data were examined, coded, and themed for important ideas that related to the research question [9].

Results

Patient views

Completed questionnaires were returned by 166 patients resulting in a 40% response rate. The majority (n = 138; 83%) found the service helpful, 21 (13%) did not, 4 (2%) did not know and 3 (2%) did not respond. The concerns of 50 (94%) of the 53 people who indicated they had a concern about their medications before their appointment were addressed, but for 2 (4%) these were not and 1 (2%) did not know. Overall 132 (80%) indicated that they understood their medicines better since the pharmacist review, 21 (13%) did not, 8 (5%) did not know and 5 (3%) did not respond. Finally, 138 (83%) people were likely or extremely likely to recommend the GP surgery to friends and family if they needed similar care or treatment; 8 (5%) were neither likely nor unlikely, 9 (5%) were unlikely or extremely unlikely and 11 (7%) were unsure. Table 1 outlines the main themes derived from analysis of qualitative responses. A small number of negative comments stated the service was not useful especially for non-English speaking patients and for those with impaired cognition.

Table 1 Themes derived from patient comments about the pharmacist-led polypharmacy medication reviews
Full size table

Discussion

The feedback received from patients about the patient-centred pharmacist-led polypharmacy medication reviews indicated that the majority found these helpful, most understood their medicines better since the review, and almost all who had concerns about their medication beforehand felt these were addressed. Qualitatively, patients appreciated pharmacists’ personal approach, advice and explanation, listening skills and ability to address their concerns; patients expressed satisfaction with the service and some felt it increased their confidence and knowledge of their medication.

The strength of this study is that it reports on an area of activity where there is a distinct lack of published research. It reports on patient views about medication reviews completed by pharmacists working within GP practices. Patients were broadly happy with the service and seeing that the service in the main involved changes being made to patient prescriptions, this paper supports the idea that pharmacist-led prescribing decisions, including de-prescribing decisions, are acceptable to patients. This is important because patients’ willingness to accept prescribing decisions is key to the long-term success of medication reviews.

The patient feedback questionnaire was validated with two pharmacists only. In addition, only 51% of those invited actually attended a review and of these only 40% returned a completed patient feedback questionnaire. Therefore there is a cohort of patients not represented by this study. In addition, this study did not measure views in the longer term. The Department of Health in England is proposing to restructure the provision of community pharmacy services with a focus on clinical services that are better integrated with primary care [10]. Studies such as the current one add to the evidence base to support a shift towards the employment of clinical pharmacists within GP practices, at least as far as short-term patient views are concerned. Future research should examine the longer-term effects of pharmacist interventions on health outcomes such as hospital admissions.

Conclusion

The majority of patients who participated in a patient-centred pharmacist-led polypharmacy medication review service within GP practices in Windsor, Ascot & Maidenhead, which had resulted in numerous changes to patients’ medication, expressed positive views about the service. Further research is needed to investigate clinical outcomes associated with such reviews.