Monitoring medication use

The advent of modern medicine has brought hope to many people with previously untreatable diseases. However, poor medication management has also led to a significant rise in adverse drug event (ADE)-associated hospital admissions. A 10-year analysis of ADEs found that the annual number admitted to hospitals increased by almost 80% and in-hospital mortality rate increased by 10%.¹

Yet international research has shown that this rapidly increasing trend, particularly among older people, is not inevitable. In fact, seven in 10 of these medication-related hospital admissions could be avoided,² potentially saving the cash-strapped Government an average of €5,500 for every preventable medication-related hospital admission.³ 

Polypharmacy report: medicines use reviews

In Ireland, one in five people aged over 50, and one in three aged over 65, regularly take five or more medications, according to the Irish Longitudinal Study on Ageing (TILDA) report on polypharmacy in older adults in Ireland, published in December 2012.⁴

Researchers at TILDA at Trinity College Dublin (TCD) warned that polypharmacy potentially puts the ageing population at greater risk of inappropriate prescribing, non-adherence and adverse drug reactions. It is also associated with functional impairment, falls and fractures, hospital admissions and mortality. The authors strongly recommended tackling this increasing human and fiscal burden by introducing regular medication reviews for those taking five or more medications – an initiative supported by the Irish Pharmacy Union (IPU) and the Pharmaceutical Society of Ireland (PSI), who have been campaigning for years for the introduction of medicines use reviews (MURs). 

Despite evidence that face-to-face MURs can help to prevent inappropriate prescribing, discrepancies between prescribed and actual regimens, poor adherence and inadequate surveillance for ADEs, the reality in Ireland is that once a medicine is dispensed, there is no further follow-up to check compliance, harmful side-effects or wastage.

Such an initiative would see, for example, a patient already taking several prescription medications for a heart condition, who is discharged from hospital after a hip replacement with new prescriptions for anti-inflammatories and painkillers, sitting down with a community pharmacist, who reviews the range of drugs prescribed and how the patient is actually using their medicine, picks up on potential interactions and instructs the patient on how to identify any side-effects. In all likelihood, should that patient experience an adverse reaction or side-effect, it will be detected before he or she ends up as one of the 12-17% of patients back in hospital because of their medicine.⁵

Role of the pharmacist

Community pharmacists have a unique role in supporting the safe and rational use of medicines. As they tend to be the link between all healthcare professionals, and the majority (75%) of patients use the same pharmacy on a regular basis, pharmacists occupy a key position in the health service that makes them attractive candidates to lead an MUR initiative in Ireland. And members of the profession in Ireland are keen to develop formalised MURs, maintaining that they will benefit patients, doctors, pharmacists and the state. The PSI’s 2011 Baseline Study of Community Pharmacy Practice in Ireland revealed that 80% of pharmacists would like to provide MURs, in collaboration with the GP and/or hospital prescribers. 

Indeed, the Irish Centre for Continuing Pharmaceutical Education’s most recent MUR training session, held in November 2012, was oversubscribed threefold within weeks of it being advertised. The tutor, Cicely Roche, an associate professor at the School of Pharmacy and Pharmaceutical Sciences, TCD, added a second training date to accommodate some of the overflow. “There is certainly an interest in the topic,” she remarked. Cicely, who developed this MUR course, explained that MURs are planned, structured, face-to-face consultations with the patient that aim to identify how patients actually use their medicines. “As international research indicates that 45% of patients do not use their medicines as prescribed or as intended, MUR services have great potential to improve patient outcomes,” she observed.

These reviews are now a normal part of the work of pharmacists in other jurisdictions, including Northern Ireland, where patients can avail of free MURs if they are taking two or more prescribed medicines for a long-term condition, or the New Medicine Service if they have been prescribed a new medicine for the first time for either an existing or newly-diagnosed health problem.

Non-compliance in patient medications

“An average of 45% of patients are non-compliant with medication regimes; in other words, they do not take the medication as prescribed or as intended, up to and including stopping it altogether. By introducing regular access to planned structured face-to-face pharmacist/patient reviews we can ultimately help improve patient outcomes. Community pharmacists already have a great relationship with our clients, we can build on this to everyone’s benefit,” she told Modern Medicine.

High levels of medication non-compliance is a major issue in healthcare. One-third of prescriptions are never filled, and patients with chronic conditions are non-compliant about half the time, studies show. The PSI baseline study found that, frequently, it is in the pharmacy that patients mention problems with medication, such as side-effects, which may be discouraging the correct use. Pharmacists can also identify compliance issues with their patients simply by observing how often prescriptions are being refilled.

“MURs can give us a picture of how the patient actually uses their medication. For the review, patients are encouraged to bring a ‘brown bag’ in which they have put all of the medication – prescription and OTC – and other herbal or complementary remedies that they are currently taking. This way, the pharmacist sees what the patient uses and a structured approach to the consultation aims to result in the patient telling the pharmacist how they actually use them,” said Cicely.

During the review of the contents of the ‘brown bag’ the pharmacist will check for incomplete or poorly labelled medicines, out-of-date medicines and irregular or over-ordering. The session also allows the pharmacist to check the inappropriate use of devices, such as inhalers. 

Depending on how complicated the patient’s medication regimen is, an MUR could take approximately half an hour of dedicated time in the pharmacist’s private consultation room. Pharmacy representative groups in Ireland suggest that MURs could be introduced on a bi-annual or annual basis, initially for patients with chronic conditions and those on multiple medications. Although MURs are currently available on an ad hoc basis to patients at some pharmacies, the IPU is keen to formalise this service and engage with the Department of Health in developing structured MURs in community pharmacies around the country, similar to those developed for a pilot project undertaken between late 2010 and early 2011, involving HSE primary care team members, GPs and pharmacists.

“A report on the project was provided by TCD to the HSE late last year. The HSE has established a Clinical Programme for Medicines Management and the report will be considered as part of the work of the Clinical Programme,” a HSE spokesperson told Modern Medicine. However, the spokesperson declined to comment on the content of the report or whether proposals to introduce pharmacist-led MURs would be implement anytime soon. Not surprisingly, the lack of progress in this regard is proving exasperating for members of the IPU and the PSI who have been calling for the implementation of MURs in Ireland for almost a decade.

“It is frustrating that nothing has yet happened. The results of the pilot study were very supportive of the roll-out of a national MUR scheme and it makes perfect sense to do so,” said Rory O’Donnell, IPU president. “Poor adherence and incorrect use of medicines are international problems, which costs health systems hundreds of billions annually, not to mention the morbidity and mortality associated with it. While pharmacists provide counselling and advice as part of our normal dispensing service, a MUR is a very different service. A typical MUR may involve analysis of a patient’s records, significant communication with the prescriber and, of course, detailed consultation with the patient. As such, it would require separate funding.” 

The prospect of unearthing investment to get this service off the ground may appear beyond reach at present, however, guardians of the health service coffers would do well to note that for every £1 spent on structured medication reviews by pharmacists in Northern Ireland, there is a saving of between £5 and £8. The Joint Committee on Health and Children 2007 report on The Adverse Side Effects of Pharmaceuticals recommended that the role of the pharmacist should be expanded and provision made for regular MURs for all patients. And this proposal was reiterated in the Economies in Drug Usage in the Irish Healthcare Setting report (2009). 

With all sides apparently in agreement that an MUR service in community pharmacy would improve compliance, reduce leakage to secondary care and reduce wastage of medicines, the introduction of these structured reviews would seem inevitable. The perennial question of when this initiative will be rolled out, however, remains unanswered.  

References 

1. Wu T-Y, Jen M-H, Bottle A et al. Ten-year trends in hospital admissions for adverse drug reactions in England 1999–2009. JRSM 2010;103(6): 239-250
2. Pirmohamed M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ 2004; 329: 15-19
3. Leendertse AJ, Van Den Bemt PM, Poolman JB et al. Preventable hospital admissions related to medication (HARM): cost analysis of the HARM study. Value Health 2011; 14(1) 34-40
4. Richardson K, Moore P, Peklar J et al. Polypharmacy in adults over 50 in Ireland: Opportunities for cost saving and improved healthcare. http://www.tcd.ie/tilda/publications/reports/
5. Ibrahim OHM. Impact of Clinical Pharmacist Intervention on Decreasing Incidence of Preventable Adverse Drug Events after Hospital Discharge. Adv Pharmacoepidem Drug Safety 2012; 1: 2