Moving anticoagulation initiation and monitoring services into the community: evaluation of the Brighton and hove community pharmacy service.

BACKGROUND: As part of the NHS desire to move services closer to where people live, and provide greater accessibility and convenience to patients, Brighton and Hove Clinical Commissioning Group (CCG) underwent a review of their anticoagulation services during 2008. The outcome was to shift the initiation and monitoring service in secondary care for non-complex patients, including domiciliary patients, into the community. This was achieved via a procurement process in 2008 resulting in the Community Pharmacy Anticoagulation Management Service (CPAMs) managed by Boots UK (a large chain of community pharmacies across the United Kingdom). METHODS: This evaluation aims to review the outcomes (International Normalised Ratio [INR] readings) and experiences of those patients attending the anticoagulation monitoring service provided by community pharmacists in Brighton and Hove. All patients on warfarin are given a target INR range they need to achieve; dosing of and frequency of appointment are dependent on the INR result. Outcome measures for patients on the CPAM service included percentage INR readings that were within target range and the percentage time the patient was within therapeutic range. Data collected from 2009 to 2016 were analysed and results compared to the service targets. Patient experience of the service was evaluated via a locally developed questionnaire that was issued to patients annually in the pharmacy. RESULTS: The evaluation shows that community pharmacy managed anticoagulation services can achieve outcomes at a level consistently exceeding national and local targets for both percentage INR readings in therapeutic target range (65.4%) compared to the recommended minimum therapeutic target range of 60.0% and percentage time in therapeutic range (72.5%, CI 71.9-73.1%) compared to the national target of 70.0%. Patients also indicated they were satisfied with the service, with over 98.6% patients rating the service as good, very good or excellent. CONCLUSION: The Brighton and Hove CPAM service achieved above average national target management of INR and positive patient feedback, demonstrating that community pharmacy is ideally placed to provide this service safely and deliver enhanced clinical outcomes and positive patient experience.

The cost effectiveness of a telephone-based pharmacy advisory service to improve adherence to newly prescribed medicines.

OBJECTIVE: This "proof of concept" study aimed to assess the cost effectiveness of pharmacists giving advice via telephone, to patients receiving a new medicine for a chronic condition, in England. METHODS: The self-regulatory model (SRM) theory was used to guide development of our intervention and used in training pharmacists to adopt a patient-centred approach. Non-adherence to new medicines for chronic conditions develops rapidly so we developed a study intervention in which a pharmacist telephoned patients two weeks after they had started a new medicine for a chronic condition. Patients were included if they were 75 or older, or were suffering from stroke, cardiovascular disease, asthma, diabetes or rheumatoid arthritis, and were randomized into treatment or control arms. Main outcome measures were non-adherence and cost to the UK NHS, obtained via a questionnaire sent two months after starting therapy. Cost of the intervention was also included. Incremental cost effectiveness ratios (ICERs) were generated. RESULTS: Five hundred patients were recruited. At 4-week follow-up, non-adherence was significantly lower in the intervention group (9% vs 16%, p=0.032). The number of patients reporting medicine-related problems was significantly lower in the intervention group compared to the control, (23% vs 34% p=0.021). Mean total patient costs at 2-month follow-up (median, range) were intervention: pound sterling 187.7 (40.6, 4.2-2484.3); control: pound sterling 282.8 (42, 0-3804) (p<0.0001). The intervention was dominant (less costly and more effective). If the decision maker is not willing to pay anything for one extra adherent patient, there is still a 90% probability that the intervention is cost effective. CONCLUSIONS: These findings suggest that pharmacists can meet patients' needs for information and advice on medicines, soon after starting treatment. While a larger trial is needed to confirm that the effect is real and sustained, these initial findings suggest the study intervention may be effective, at least in the short term, with a reduced overall cost to the health provider.

Patient-centred advice is effective in improving adherence to medicines.

OBJECTIVE: To assess the effects of pharmacists giving advice to meet patients' needs after starting a new medicine for a chronic condition. METHOD: A prospective health technology assessment including a randomised controlled trial of a pharmacist-delivered intervention to improve adherence using a centralised telephone service to patients at home in England. Patients were eligible for recruitment if they were receiving the first prescription for a newly prescribed medication for a chronic condition and were 75 or older or suffering from stroke, cardiovascular disease, asthma, diabetes or rheumatoid arthritis. MAIN OUTCOME MEASURES: Incidence of non-adherence, problems with the new medicine, beliefs about the new medicine, safety and usefulness of the interventions. RESULTS: Five hundred patients consented and were randomised. At 4-week follow-up, non-adherence was significantly lower in the intervention group compared to control (9% vs. 16%, P = 0.032). The number of patients reporting medicine-related problems was significantly lower in the intervention group compared to the control (23% vs. 34%, P = 0.021). Intervention group patients also had more positive beliefs about their new medicine, as shown by their higher score on the "necessity-concerns differential" (5.0 vs. 3.5, P = 0.007). The phone calls took a median of 12 min each. Most advice was judged by experts to be safe and helpful, and patients found it useful. CONCLUSION: Overall, these findings show benefits from pharmacists meeting patients' needs for information and advice on medicines, soon after starting treatment. While a substantially larger trial would be needed to confirm that the effect is real and sustained, these initial findings suggest the service may be safe and useful to patients.