Pharmaceutical care practice : drug-related problems and opportunities for new services

Within the last decades, the role of the pharmacist and of pharmacy practice have moved from that of drug manufacturing and technical dispensing to a more cognitive role with patient orientation. The concept of pharmaceutical care focuses on the process of ‘using a drug’, bearing in mind that the dispensing of a drug is neither the beginning nor the end of this process. Pharmaceutical care is based on a relationship between the patient and the pharmacist who accepts responsibility for the patient. However, much of the impetus for pharmaceutical care provision has been driven by academics, and only limited published data on the extent to which pharmaceutical care has been adopted and implemented are available.
The aim of project A was to evaluate the current provision of pharmaceutical care by European community pharmacists and the impact of a range of factors that could affect its implementation. For this study, the behavioural pharmaceutical care scale (BPCS) was used. A total of 4,696 questionnaires were obtained. The mean total BPCS scores ranged from 50.6 (Denmark; DK) to 83.5 (Ireland). The results of project A suggest that the provision of pharmaceutical care in a comprehensive fashion is still limited within Europe. Pharmacists rarely documented activities related to patient care and did not often engaged in implementing therapeutic objectives and monitoring plans.
With project B, we aimed to explore differences between standard pharmacists, pharmacists participating in quality circles, and Danish pharmacists. Moreover, discussion of the BPCS’ reliability and applicability as a research tool for pharmacy practice was of interest. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6% (DK) to 45.8% (CH). The specialised QC and Danish pharmacists reached significantly lower scores than Swiss and German pharmacists. Our results show that pharmacies in all regions are adequately equipped to provide pharmaceutical care. However, the provision of pharmaceutical care mainly occured when pharmacists were supported by their computer system. The findings cast doubt on the results of the whole BPCS study, and the question arises if the BPCS is a sensitive scale to enable a conclusion about the extent to which pharmaceutical care is provided to patients.
To evaluate the benefit of pharmaceutical care, we need tools to describe and document drug-related problems (DRPs) and to measure their impact on patient outcomes. However, no accepted standard tool for classification of DRPs has been made available so far. The aims of project C were to explore the occurrence of DRPs with new prescriptions and to analyse differences between primary care and hospital discharge. Furthermore, we aimed to evaluate the applicability of a modified classification system. Prescriptions of 616 patients were analysed. In 19.6% of all prescriptions, 141 clinical DRPs were detected. The most frequent clinical DRPs were potential drug-drug interactions (37.6%), drug choice (24.8%), and drug use problems (15.6%). There were 222 prescriptions (36.0%) that contained 278 technical DRPs. The most frequent technical DRPs were unclear package size or therapy duration (32.7%) and unclear dosing instructions (30.9%). The results of this study showed that clinical and technical DRPs were frequently observed and that the number of prescribed drugs was the only factor with an influence on the frequency. The modified classification system, especially the amendment with a technical DRP category, proved to be useful and allowed the classification of all DRPs, but remained rather complicated to apply in pharmacy practice.
To get insight into the patients’ medication management, it may be useful to visit patients at home. Although recent studies indicated that pharmacist-led medication reviews and home visits are potentially beneficial, it is still an open question if tailored medication reviews are needed. With project D – a pilot study – we set the goal to explore patients’ knowledge about newly prescribed medication and to gain first experiences in performing home visits. We conducted 70 phone interviews with patients who received newly prescribed medications some days ago. Only 35% of drug names could be given by patients. However, 92% of all stated purposes of drugs were correct. Out of 70 interviewed patients, 20 agreed to be visited at their home. Two (10.0%) patients had drug use problems, seven (35.0%) suffered from adverse drug events. The patients’ knowledge a few days after receiving newly prescribed drugs was rather good. Home visits of such patients showed to be a feasible service for community pharmacists.
In project E, we aimed to analyse the number and pattern of DRPs at patients’ home. Two investigators visited 54 diabetes type 2 (DM) and 22 solid organ transplant (Tx) patients in their homes, using a structured interview guide. The mean number of drugs was 12.5 ± 4.4 (Tx) and 13.9 ± 5.4 (DM). We identified significant differences between the number of DRPs of Tx and DM patients (6.3 ± 1.7 vs. 7.8 ± 2.5; p=0.010). The most relevant DRPs in Tx and DM patients were uncertainty about one or multiple purposes or justification of drugs (36.4%; 48.1%), no basic knowledge about potential interactions (18.2%; 61.1%), confusion of generic and trade names (27.3%; 74.1%), and risk for non-adherence (77.3% and 61.1%). Among all patients, 11 (14.5%) reported to have problems with their drugs. If interviews had been conducted at the pharmacies rather than the patient homes, we most probably would have detected only 48.6% of DRPs. The results of this study indicated that more tailored interview guides for different
diseases would enable more efficient home visits. The most frequently observed DRPs are important shortcomings which easily can be solved by pharmacists.