Large scale implementation of clinical medication reviews in Dutch community pharmacies: drug-related problems and interventions.

BACKGROUND: Research on the benefits of clinical medication reviews (CMRs) performed by pharmacists has been conducted mostly in controlled settings and has been widely published. Less is known of the effects after large scale implementation in community pharmacies. An online CMR tool enabled the systematic registration of drug-related problems (DRPs) and implemented interventions derived from CMRs in daily practice. OBJECTIVE: To describe the effects of CMRs on pharmacy practice after large-scale implementation in the Netherlands. SETTING: 268 community pharmacies. Pharmacists were trained on CMRs with a patient centred approach. METHOD: Retrospective analyses of DRPs, pharmacists' proposals and implemented interventions recorded between January 1st and September 1st 2012. MAIN OUTCOME MEASURE: Frequencies of DRPs, intervention proposals, implemented interventions, and drugs involved. RESULTS: 4,579 CMRs were analysed. On average 2.9 (SD 2.1) DRPs per review were identified. 4,123 (31 %) of the DRPs led to medication changes. Stopping a drug (16 %) was more frequent than starting a drug (8.1 %). Drugs related to cardiovascular risk management, diabetes and osteoporosis were most frequently involved. CONCLUSION: This study is the largest analysis of pharmacists-initiated CMRs in the Netherlands to date. The findings demonstrate the potential to reduce medication-related errors through pharmacist involvements in complex pharmacotherapy and the positive impact on the quality of drug therapy through making necessary medication changes. The data also support the need for large-scale implementation of pharmacists-initiated CMRs in the presence of proper training programmes.

The usefulness of antiplatelet prescriptions for the identification of patients with atherothrombosis in primary care: a Dutch cross-sectional study.

RATIONALE, AIMS AND OBJECTIVES: Patients with atherothrombotic cardiovascular disease (ACD) should receive specific treatments, including lipid-lowering medication. In order to optimize treatment for patients with ACD in primary care, an efficient method to identify all these patients is needed. We aimed to assess which method serves best to identify all patients with ACD in Dutch primary care: morbidity records, antiplatelet prescribing records or a combination of these. METHODS: In a cross-sectional study in 45 Dutch general practices, computerized medical records of all patients with any cardiovascular disease, cardiovascular symptoms or cardiovascular medication were analysed. RESULTS: Of the 7280 patients with a recorded indisputable indication for antiplatelet therapy, 4715 (64.8%) could be identified by means of antiplatelet prescriptions. Of the patients with a recorded indisputable indication for antiplatelets but without any antiplatelet prescription, 28.9% received a vitamin K antagonist. Of the 8718 patients with antiplatelet therapy, 5697 (65.3%) could be identified by means of a recorded indisputable or possible indication for antiplatelet therapy. Female patients, patients younger than 60 years old and patients having a recorded diagnosis of angina pectoris or diabetes had a higher risk to be missed by antiplatelet prescribing records. CONCLUSION: Morbidity records and prescribing records should be used both in order to identify all patients with ACD in primary care. Patients who use antiplatelet prescriptions but do not have a recorded ACD deserve extra attention, because they are either treated without a good indication for antiplatelet therapy (overtreatment) or need a correction of their morbidity records.

Implementation of a pharmacist-led intervention to enhance statin prescribing for secondary prevention in primary care: a cluster randomized trial.

BACKGROUND: Although statins have indisputably proven to reduce fatal and nonfatal events in patients with cardiovascular disease, many patients with established cardiovascular disease do not receive them. Research into the effective and efficient implementation of current guidelines on secondary prevention is therefore needed. DESIGN: A cluster randomized implementation trial was conducted between September 2006 and February 2008. METHODS: Experimental pharmacists received an intensive implementation programme, whereas control pharmacists received an educational manual only. Pharmacists in both the groups were asked to identify eligible patients and to provide general practitioners (GPs) with lists of these patients. Physicians received instructions from the pharmacists to review the patients regarding a statin indication and to start a statin when they considered this as appropriate. Main outcome measure was the percentage of identified patients who received one or more statin prescriptions at 6 months follow-up. RESULTS: Although twice as many patients were reviewed for a statin indication by a GP in the experimental group (19.7 vs. 10.8%, P = 0.023), an equally low number of patients in the experimental group and the control group received statins (5.8 vs. 5.3%, P = 0.104). CONCLUSION: The intensive implementation programme had an impact on pharmacists and GPs, but did not result in more patients receiving statins.

Implementation of patient education at first and second dispensing of statins in Dutch community pharmacies: the sequel of a cluster randomized trial.

BACKGROUND: As a result of the previous part of this trial, many patients with cardiovascular disease were expected to receive a statin for the first time. In order to provide these patients with comprehensive information on statins, as recommended by professional guidance, education at first and second dispensing of statins had to be implemented. This study was designed to assess the effectiveness of an intensive implementation program targeted at pharmacy project assistants on the frequency of providing education at first dispensing (EAFD) and education at second dispensing (EASD) of statins in community pharmacies. METHODS: The participating community pharmacies were clustered on the basis of local collaboration, were numbered by a research assistant and subsequently an independent statistician performed a block randomization, in which the cluster size (number of pharmacies in each cluster) was balanced. The pharmacies in the control group received a written manual on the implementation of EAFD and EASD; the pharmacies in the intervention group received intensive support for the implementation. The impact of the intensive implementation program on the implementation process and on the primary outcomes was examined in a random coefficient logistic regression model, which took into account that patients were grouped within pharmacy clusters. RESULTS: Of the 37 pharmacies in the intervention group, 17 pharmacies (50%) provided EAFD and 12 pharmacies (35.3%) provided EASD compared to 14 pharmacies (45.2%, P = 0.715) and 12 pharmacies (38.7%, P = 0.899), respectively, of the 34 pharmacies in the control group. In the intervention group a total of 72 of 469 new statin users (15.4%) received education and 49 of 393 patients with a second statin prescription (12.5%) compared to 78 of 402 new users (19.4%, P = 0.944) and 35 of 342 patients with a second prescription (10.2%, P = 0.579) in the control group. CONCLUSION: The intensive implementation program did not increase the frequency of providing EAFD and EASD of statins in community pharmacies. TRIAL REGISTRATION: clinicaltrials.gov NCT00509717.

Implementation of adherence support for patients with hypertension despite antihypertensive therapy in general practice: a cluster randomized trial.

BACKGROUND: Uncontrolled hypertension despite treatment is highly prevalent among hypertension patients. Electronic monitoring of medication adherence has been proven to be effective in improving blood pressure. The aim of the study was to compare the effectiveness of intensive support for implementation of this tool in community pharmacies with minimal implementation support. METHODS: In a cluster randomized trial, 25 control pharmacies received a manual and 32 experimental pharmacies received intensive support to enhance implementation of electronic monitoring. PRIMARY OUTCOME: the number of patients included for electronic monitoring. Secondary outcomes included mean change in systolic blood pressure (SBP) and percentage of patients with adequate SBP control. RESULTS: The experimental group yielded consistently higher scores on all the steps of the implementation process than the control group, but none of these differences were significant. The mean number of patients per pharmacy included for electronic monitoring in a 3-9-months period was 1.6 in the experimental group vs. 1.0 in the control group (difference = 0.7, 95% confidence interval = -0.4; 1.7). The following patient outcomes were pooled because there were no differences between the experimental and the control group. Mean change of SBP/diastolic blood pressure (DBP) was -12 and -6 mm Hg, respectively, SBP dropped <140 mm Hg in 20.9% of all patients. In 13.6% of all patients control of SBP was achieved without treatment intensification. CONCLUSION: The intensive implementation program enhanced pharmacist performance, but appeared insufficient to overcome all problems with the implementation of electronic monitoring. The major restrictive factors concerned general practitioner (GP) involvement and the identification of eligible patients.

Implementation of a discontinuation letter to reduce long-term benzodiazepine use--a cluster randomized trial.

RATIONALE: Although it is recommended to restrict long-term use of benzodiazepines, and considerable attention has been paid to this, long-term use continues to be a problem. An informative discontinuation letter for patients has been shown to reduce long-term benzodiazepine use in general practice. However, little is known about its wide scale implementation in primary care. OBJECTIVE: To determine the effectiveness of an intensive support programme for community pharmacies to send discontinuation letters to patients in cooperation with GPs. METHODS: In a cluster randomized trial, 43 control pharmacies received a written manual and 47 experimental pharmacies received an intensive support programme. Primary outcome measures were the percentage of GPs who reviewed and returned lists of eligible patients and the percentage of long-term users who were sent a discontinuation letter within 4 months. RESULTS: The outcomes did not differ for the experimental versus control groups: 38% and 31% of the GPs, respectively, returned the patient lists; 14% and 10% of all long-term users in the two groups, respectively, received the discontinuation letter within 4 months. Substantially more pharmacies in the experimental group than in the control group finally managed to send discontinuation letters (70% vs. 40%). CONCLUSION: About one third of the pharmacies in the control group and two thirds of the pharmacies in the intervention group finally implemented the discontinuation letter. However, this difference was not apparent in the primary outcome measures. It seems crucial to involve GPs more effectively in implementation of the discontinuation letter.