June Tordoff

A systematic review and meta-analysis of pharmacist-led fee-for-services medication review

AIMnThe aim was to examine the impact of fee-for-service pharmacist-led medication review on patient outcomes and quantify this according to the type of review undertaken, e.g. adherence support and clinical medication review.nnnMETHODSnRelevant published studies were identified from Medline, Embase and International Pharmaceutical Abstract databases (from inception to February 2011). Study inclusion criteria were fee-for-service medication review, presence of a control group and pre-specified patient outcomes. Outcomes were grouped into primary (changes in biomarkers, hospitalization, and mortality) and secondary outcomes (medication adherence, economic implications and quality of life). Meta-analyses for primary outcomes were conducted using random effects models and secondary outcomes were summarized using descriptive statistics.nnnRESULTSnOf the 135 relevant articles located, 21 studies met the inclusion criteria for primary outcomes and 32 for secondary outcomes. Significant results favouring pharmacists intervention were found for blood pressure (OR 3.50, 95% CI 1.58, 7.75, P = 0.002) and low density lipoprotein (OR 2.35, 95% CI 1.17, 4.72, P = 0.02). Outcomes on hospitalization (OR 0.69, 95% CI 0.39, 1.21, P = 0.19) and mortality (OR 1.50, 95% CI 0.65 to 3.46, P = 0.34) indicated no differences between the groups. On subgroup analysis, clinical medication review (OR 0.46, 95% CI 0.26, 0.83, P = 0.01) but not adherence support review (OR 0.88, 95% CI 0.59, 1.32, P = 0.54) reduced hospitalization.nnnCONCLUSIONSnThe majority of the studies (57.9%) showed improvement in medication adherence. Fee-for-service pharmacist-led medication reviews showed positive benefits on patient outcomes. Interventions that include a clinical review had a significant impact on patient outcomes by attainment of target clinical biomarkers and reduced hospitalization.

Continuation of Proton Pump Inhibitors from Hospital to Community

ObjectivesTo evaluate the appropriateness of initiation of proton pump inhibitor (PPI) treatment in hospital, the quality of discharge information, and any association with continued treatment in the community.MethodSurvey of all inpatients newly initiated on a PPI in June–August 2003. Assessment of appropriateness of therapy and completeness of discharge information; assessment of continuation of PPI therapy in the community after 6xa0months.ResultsThirty-five of 58 patients (60%) were considered appropriately commenced on PPI treatment. Less than 25% of patients discharged on a PPI had discharge information recommending duration of treatment or review. In the “appropriate” group 30 patients (86%) were discharged on omeprazole, and 13/21 (62%) evaluable patients remained on this at 6xa0months. In the “inappropriate” group 15 (65%) were discharged on omeprazole, and 10/14 (71%) evaluable patients remained on this at 6xa0months. Older patients remained on omeprazole for a longer duration but appropriateness of commencement did not influence the duration of treatment. Dose titration was attempted for 10 (29%) patients including three from the “inappropriate” group.ConclusionCare should be taken to commence PPIs only when clinically indicated. Discharge information to GPs, especially recommendations for duration of treatment and/or dose titration, requires improvement.

Medicine-taking practices in community-dwelling people aged ≥75 years in New Zealand

BACKGROUNDnolder people experience more chronic medical conditions than younger people, take more prescription medicines and are more likely to suffer from cognitive or memory problems. Older people are more susceptible to the adverse effects of medicines, which may reduce their quality of life or lead to hospitalisation or death.nnnOBJECTIVEnthis study aims to identify medicine-taking practices amongst community-dwelling people aged > or =75 years in New Zealand.nnnMETHODSnthis study was carried out in an urban setting in Dunedin (population 120,000), New Zealand. Interviews of a random sample of people from the electoral roll using a structured questionnaire were conducted. Subjects were community-dwelling people aged > or =75 years taking one or more prescription medicines. From a random sample of 810 people extracted from the electoral roll intended to recruit 300 participants, 524 people met the study criteria and were invited to participate. People living in a rest home or hospital, not contactable by telephone, or now deceased, were excluded. Responses were analysed, medicines categorised by the Anatomical Therapeutic Chemical classification and adherence classed as high, medium and low using a modified four-item Morisky Medication Adherence Scale. Univariate and multivariate linear and logistic regression was applied to combinations of variables.nnnRESULTSnin total, 316 interviews were undertaken; a 61% response rate. Participants were 75-79 (35%), 80-84 (40%) and >85 years (25%); New Zealand European/European (84%), New Zealanders (14%) or Maori (2%); and 141 (45%) lived alone. Almost half (49%) regularly saw a specialist and a third (34%) had been admitted to hospital in the past 12 months. Participants used a median of seven prescription medicines (range 1-19) and one non-prescription medicine (0-14). The majority (58%) believed medicines are effective and had systems/routines (92%) for remembering to take them. Doses tended to be missed following a change in routine, e.g. holiday. Men were more likely to report trouble remembering than women (odds ratio = 1.86, 95% confidence interval 1.10-3.14; P = 0.020). Seventy-five percent of people had high or medium adherence scores and 25%, low scores. Common problems were reading and understanding labels (9 and 4%, respectively) and leaflets (12%, 6%), and difficulty swallowing solid dose forms (14%). Only 6% had problems paying for their medicines. Around 17% wanted to know more about their medicines, and some people were confused about their medicines following hospital discharge.nnnCONCLUSIONnoverall, community-dwelling people aged > or =75 years in this study appeared to manage their medicines well and found them affordable. Nevertheless, there is a need to improve labelling, leaflets and education on medicines, particularly at hospital discharge.

General practitioners’ perceptions of pharmacists’ new services in New Zealand

Background In recent years, the pharmacy profession has moved towards more patient-oriented services. Some examples are medication review, screening and monitoring for disease, and prescribing. The new services are intended to be in close collaboration with general practitioners (GPs) yet little is known of how GPs in New Zealand perceive these new services. Objective To examine GPs’ perceptions of pharmacists’ new services. Setting Study was undertaken at GPs’ practices in two localities in New Zealand. Methods Qualitative, face to face, semi-structured interviews were undertaken of 18xa0GPs. The cohort included GPs with less/more than 20xa0years of practice, and GPs who had experience of working in localities where some patients had undergone a medication review (Medicines Use Review, MUR) by community pharmacists. GPs were asked to share their perceptions about pharmacists providing some new services. Data were thematically analysed with constant comparison using NVivo 8 software. Using a business strategic planning approach, themes were further analysed and interpreted as the services’ potential Strengths, Weaknesses, Opportunities and Threats (SWOTs). Main outcomes measure GPs’ perceptions of pharmacists’ new services. Results GPs were more supportive of pharmacists’ playing active roles in medication review and less supportive of pharmacists practising screening-monitoring and prescribing. Discussions Pharmacists’ knowledge and skills in medication use and the perceived benefits of the services to patients were considered the potential strengths of the services. Weaknesses centred around potential patient confusion and harm, conflict and irritation to GPs’ practice, and the potential to fragment patient-care. Opportunities were the possibilities of improving communication, and having a close collaboration and integration with GPs’ practice. Apparent threats were the GPs’ perceptions of a related, and not renumerated, increase in their workloads, and the perception of limited benefit to patients. Conclusion Pharmacists should exploit their own strengths and the potential opportunities for these services, and reduce any weaknesses and threats. A possible strategic plan should include increased effective communication, piloting services, and the integration of some services into medical practices.

Potentially inappropriate medicines in a cohort of community‐dwelling older people in New Zealand

To examine independent factors associated with potentially inappropriate medicines (PIM) among 316 community‐dwelling people aged ≥75 years living in Dunedin.

It's just routine. A qualitative study of medicine-taking amongst older people in New Zealand

Aim To explore how New Zealanders aged 65 years and older manage their medicines in their own homes, and determine the problems and concerns they might have with taking them. Setting Urban setting, Dunedin (population 120,000), New Zealand. Methods Twenty in-depth semi-structured interviews were undertaken of community-dwelling people 65 years and older. Sixty people, from a random sample of 80 from the electoral roll, met the recruitment criteria and were invited to participate. The first ten men and ten women agreeing to participate were interviewed. Interviews were taped and transcribed verbatim. Transcriptions were thematically coded and analysed using grounded theory and constant comparison. Main Outcome Measures Emerging themes were explored under the topics: accessing medicines, remembering to take medicines, following instructions, practical problems, adverse effects, concerns about medicines, and beliefs about medicines. Results Ten of thirteen men and 10/20 women contacted (61%) agreed to participate. The men were aged 71, 67–82xa0years (median, range) and women 77, 69–87xa0years. They were using 140 prescription medicines (median 7, range 3–16) and 34 non-prescription medicines (1, 0–6); mainly for the nervous system (28%), or the cardiovascular system (22%). Participants felt that they had good access to medicines, could afford them, managed them well, and had systems and routines to help them remember to take them. Occasional doses were missed following a change in routine. Practical problems were found such as difficulty swallowing or halving tablets. Three-quarters of participants had experienced adverse effects during their lives. These were managed by dose or drug changes or by taking practical measures. People were worried about adverse effects occurring whether or not they had experienced them previously. Beliefs about medicines were mainly positive, although some people disliked taking them. Conclusion The people 65 years and over in this study felt that they could access, afford and manage their medicines well. Although many participants had experienced adverse effects, their beliefs about medicines were mainly positive. Practical problems and concerns should be routinely enquired about and addressed, and prescribing and monitoring optimised to minimise adverse effects, in order to assist older people take their medicines.

A 3-Dimensional View of Access to Licensed and Subsidized Medicines under Single-Payer Systems in the US, the UK, Australia and New Zealand

AbstractIntroduction: Patients’ access to medicines can be profoundly affected by the decisions made by medicine licensing bodies and public reimbursement agencies. The present study compares access to licensed and subsidized medicines under a single-payer system in each of the US, the UK, Australia and New Zealand (NZ). These systems are the US Department of Veterans Affairs National Formulary (VANF), the UK NHS for England and Wales, Australian Pharmaceutical Benefits Scheme (PBS) and NZ’s Pharmaceutical Management Agency (PHARMAC). The VANF, PBS and PHARMAC all use positive lists of medicines that are subsidized, along with pharmacoeconomic analysis and price negotiations with suppliers. The NHS uses a negative list of medicines that are not to be subsidized, along with pharmacoeconomic analysis of a small number of medicines and caps on manufacturers’ profits.n Objective: Our objective was to compare licensed and subsidized medicines in terms of the following: (i) total numbers of entities (unique Anatomical Therapeutic Chemical [ATC] codes); (ii) times since first registration (age) of the entities; and (iii) numbers of innovative entities.n Methods: This was an observational study in order to test pre-defined hypotheses. All products listed in a major prescribing reference in each country were included in the study. All products were classified by ATC code and their registration dates recorded. Products were collapsed by ATC code to determine ‘best-case’ licensing and subsidy for each entity, along with the date of first registration. Innovative entities selected for ‘fast-track’ approval by the US FDA or as a ‘breakthrough or substantial improvement’ by the Canadian Patented Medicines Prices Review Board were identified. Results were verified by a sensitivity analysis that excluded entities only available in injectable formulations (as these may not always be listed in general prescribing references), and by a parallel analysis done by active agent rather than ATC code.n Results: Of the 918 entities and 64 innovative entities licensed in the US, 505 and 20, respectively, were subsidized by the VANF. In the UK, this was 1020 and 58 (1016 and 58 NHS subsidized); in Australia, this was 879 and 49 (567 and 30 PBS subsidized); and in NZ, this was 765 and 39 (503 and 19 PHARMAC subsidized). With the exception of the UK, entities licensed in the US were newer than elsewhere. The median ages were as follows: 6607 days in the US (VANF subsidized 8203 days; p<0.001); 7319 days in the UK (NHS subsidized 7319 days; p=0.903); 7795 days in Australia (PBS subsidized 8065 days; p=0.406); and 8936 days in NZ (PHARMAC subsidized 10724 days; p < 0.001). NHS subsidized entities were newer than elsewhere. VANF and PHARMAC subsidized entities were significantly older than licensed entities in their respective countries.n Conclusion: The single-payer systems examined differ in the number and age of licensed and subsidized entities, along with access to innovative entities. The NHS subsidized the most entities, the newest entities and the most innovative entities. NZ’s PHARMAC system subsidized the fewest and oldest entities, and the fewest innovative entities. The VANF and PBS consistently fell between the other two systems in terms of the number of subsidized entities, age of subsidized entities and number of subsidized innovative entities.

Challenges and Enablers of Deprescribing: A General Practitioner Perspective.

Aims Deprescribing is the process of reducing or discontinuing medicines that are unnecessary or deemed to be harmful. We aimed to investigate general practitioner (GP) perceived challenges to deprescribing in residential care and the possible enablers that support GPs to implement deprescribing. Methods A qualitative study was undertaken using semi-structured, face-to-face interviews from two cities in New Zealand and a purpose-developed pilot-tested interview schedule. Interviews were recorded with permission and transcribed verbatim. Transcripts were read and re-read and themes were identified with iterative building of a coding list until all data was accounted for. Interviews continued until saturation of ideas occurred. Analysis was carried out with the assistance of a Theoretical Domains Framework (TDF) and constant comparison techniques. Several themes were identified. Challenges and enablers of deprescribing were determined based on participants’ answers. Results Ten GPs agreed to participate. Four themes were identified to define the issues around prescribing for older people, from the GPs’ perspectives. Theme 1, the ‘recognition of the problem’, discusses the difficulties involved with prescribing for older people. Theme 2 outlines the identified behaviour change factors relevant to the problem. Deprescribing challenges were drawn from these factors and summarised in Theme 3 under three major headings; ‘prescribing factors’, ‘social influences’ and ‘policy and processes’. Deprescribing enablers, based on the opinions and professional experience of GPs, were retrieved and summarised in Theme 4. Conclusion The process of deprescribing is laced with many challenges for GPs. The uncertainty of research evidence in older people and social factors such as specialists’ and nurses’ influences were among the major challenges identified. Deprescribing enablers encompassed support for GPs’ awareness and knowledge, improvement of communication between multiple prescribers, adequate reimbursement and pharmacists being involved in the multidisciplinary team.

The impact of pharmaceutical cost containment policies on the range of medicines available and subsidized in Finland and New Zealand.

OBJECTIVEnTo identify differences in the range of medicines available and subsidized for ambulatory care in Finland and New Zealand.nnnMETHODSnMedical entities listed in national product information sources and their subsidy statuses were compared. The number and overlap of entities available and subsidized were determined. Differences in the age of subsidized medicines were compared using the date of first registration. Differences in licensing delays were compared using a selection of new innovative medicines that provide health gain.nnnRESULTSnWithin the inclusion criteria, 779/763 entities were available and 495/471 subsidized in Finland/New Zealand, of which around 30% (30.9% Finland, 29.5% New Zealand) were not available and approximately 40% (41.4% Finland, 38.4% New Zealand) not subsidized in the other country. The proportion of fully subsidized entities was higher in New Zealand (86.2%/29.1%). The entities only subsidized in New Zealand were significantly older than those only subsidized in Finland and the share of licensed and launched innovative medicines was significantly smaller in New Zealand. The differences were equally distributed across the therapeutic groups but clinically relevant differences were rarely found.nnnCONCLUSIONSnIn New Zealand, medicines are heavily subsidized across therapy groups, but those uniquely subsidized were older entities. In Finland, more newer medicines are subsidized and available, but the level and coverage of subsidy is lower and thus, the patient cost burden is higher. The cost containment policies adopted seem to affect patients access to medicines mainly by availability in New Zealand and by affordability in Finland.

“Price Management” and Its Impact on Hospital Pharmaceutical Expenditure and the Availability of Medicines in New Zealand Hospitals

OBJECTIVESnIn 2002, the Pharmaceutical Management Agency (PHARMAC) began negotiating new price contracts for 90% of hospital pharmaceuticals on behalf of all New Zealand (NZ) public hospitals (price management[PM]). The present study was undertaken to examine the impact of 3 years of PM on hospital pharmaceutical expenditure, and the impact of the new contracts on the availability of medicines.nnnMETHODSnAnnual savings for 29 major public hospitals (financial years 2003/4 to 2005/6) were calculated from the data from 11 hospitals and data from PHARMAC. Inpatient and total hospital pharmaceutical expenditure (IPE, THPE) (2000/1 to 2005/6) were calculated from the data from 23 hospitals. Hospital pharmaceutical expenditure (2000/1 to 2005/6) was compared with community pharmaceutical expenditure (CPE) in NZ, and with THPE in the UK, Canada, Norway, and Sweden. Surveys were undertaken (2004, 2005) to examine any changes in medicine availability resulting from the new contracts.nnnRESULTSnAnnual savings were NZ