Can a practice pharmacist improve prescribing safety and reduce costs in polypharmacy patients? A pilot study of an intervention in an Irish general practice setting.

OBJECTIVES: This study aimed to develop and assess the feasibility and cost impact of an intervention involving a practice pharmacist embedded in general practice to improve prescribing safety, deprescribe where appropriate and reduce costs. SETTING: Four-doctor suburban general practice. PARTICIPANTS: Inclusion criteria: patients receiving 10+ repeat drugs per month. EXCLUSION CRITERIA: deceased, <18 years of age, nursing home resident, no longer attending, late-stage life-limiting condition, unsuitable on clinical/capacity grounds. 137 patients were eligible. 78 were recruited as participants, all of whom completed the study. INTERVENTION: Pharmacist conducting holistic medication reviews in the study group over a 6-month period. PRIMARY OUTCOME MEASURES: Anonymised medication changes, cost, biochemical monitoring and clinical measurements data were collected. Cost analysis of having a pharmacist as part of the general practice team was calculated. RESULTS: In total, 198 potentially inappropriate prescriptions (PIPs), and 163 opportunities for deprescribing were identified; 127 PIPs (64.1%) were actioned; 104 deprescribing opportunities were actioned (63.8%). The pharmacist identified 101 instances in which further investigations were warranted prior to prescription issue, of which 80 were actioned (79.2%). It was calculated that monthly savings of €1252 were made as a result of deprescribing. CONCLUSIONS: This study has shown that the integration of pharmacists within general practice in Ireland is feasible and is an effective means of improving prescribing safety and implementing deprescribing through medication reviews. The combination of safety and cost concerns support taking a holistic approach to deprescribing with the patient. This study highlights the ease with which a pharmacist could integrate into the general practice setting in Ireland and points to how this could be sustainably funded.

Acceptability and accuracy of oral fluid drug testing for patients on methadone maintenance.

BACKGROUND: Methadone maintenance is currently the predominant form of opioid substitution treatment available in the Republic of Ireland. Prescribing decisions currently involve urine testing for drug use. Urine testing may involve provision of a supervised sample in some circumstances, despite recommendations made in 2010 to abandon this practice. AIMS: This project aims to evaluate the accuracy and acceptability of oral fluid testing for patients on methadone maintenance and also gather patient views on their treatment. METHODS: Patients attending for methadone maintenance at 4 general practices were invited to take part in this study, which involved taking an additional oral fluid test and a questionnaire. RESULTS: Fifty-five patients agreed to participate. Fifty-two (95%) found the oral fluid test acceptable, and almost two-thirds would prefer to see it used instead of urine testing. Oral fluid provided similar results to urine testing for all drugs except benzodiazepines. Self-report identified cocaine and opiate use not detected by oral fluid or urine testing. CONCLUSION: This study presents evidence that oral fluid testing is acceptable to most patients. While oral fluid testing was inferior to urine testing for benzodiazepines, it may have an adjunctive role to play in methadone maintenance provision. Patients reported more negative than positive aspects of methadone maintenance.

Free Children's Visits and General Practice Attendance.

PURPOSE: In July 2015, all children aged younger than 6 years gained free access to daytime and out-of-hours general practice services in the Republic of Ireland. Although 30% previously had free access, 70% did not. METHODS: To examine subsequent changes in service use, we retrospectively analyzed anonymized visitation data from 8 general practices in North Dublin providing daytime service and their local out-of-hours service, comparing the 1 year before and the 1 year after introduction of free care. RESULTS: In the year after granting of free general practice care for children younger than 6 years, 9.4% more children attended the daytime services and 20.1% more children were seen in the out-of-hours services. Annual number of visits by patients increased by 28.7% for daytime services and by 25.7% for out-of-hours services, translating to 6,682 more visits overall. Average visitation rate for children this age increased from 2.77 visits per year to 3.25 visits per year for daytime services, but changed little for out-of-hours services, from 1.52 visits per year to 1.59 visits per year. CONCLUSIONS: Offering free childhood general practice services led to a dramatic increase in visits. This increase has implications for future health care service planning in mixed public and privately funded systems.