The pharmacist recorded all medication-related issues that were identified at each visit or consultation. The issues were later classified according to the Hepler and Strand model, which comprises 8 categories of drug- related problems: untreated indication, improper drug selection, subtherapeutic dose, failure to receive a needed medication, overdose, adverse drug reaction, drug interaction, and drug use without an indication. An additional category (“other”) was used to capture medication-related issues that did not fit within any of these 8 categories.
The pharmacist recorded all of the recommendations that were made to optimize patients’ medication regimens. The recommendations were classified according to the following categories: start medication, discontinue medication, change medication, change dose or instructions, perform testing for and/or monitor laboratory parameters or monitor patient symptoms, provide education to patient or caregiver, and monitor or provide instruction about adherence. The recipient of each recommendation (i.e., the physician, the nurse, or the patient or caregiver) was also recorded, along with an indication of whether the recommendation was accepted. For physicians only, a further distinction was made between recommendations that were actively rejected and those for which the outcome was unknown (for example, if the patient was readmitted to hospital or the medical situation changed before the recommendation could be processed, the status of the recommendation was classified as unknown).
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Significance of Pharmacist’s Recommendations
The clinical significance of the pharmacist’s recommendations was rated (by the first author, S.M.) according to a published 6-point scale, where
1 = adverse significance (may lead to adverse outcome),
2 = no significance (informational), 3 = somewhat significant, 4 = significant (in line with standards of practice), 5 = very significant (potential or existing major organ dysfunction), and 6 = extremely significant (life- or-death situation). A second pharmacist, who was not involved with the study, independently rated the recommendations for 6 patients, such that 37 (32%) of the 116 recommendations were rated by both individuals; the 2 raters agreed on 32 of the 37 joint ratings (86% agreement). For the 5 ratings with disagreement, the raters disagreed by 1 point on the scale, and agreement was reached through discussion.
After completion of the visits, a research assistant telephoned the patients or caregivers to determine their satisfaction with 5 aspects of the clinical pharmacy services provided (rated on a scale of 0 [not at all satisfied] to 10 [completely satisfied]): overall satisfaction, satisfaction with the pharmacist’s knowledge about medications, satisfaction with the pharmacist’s medication-taking advice, satisfaction with the pharmacist’s professionalism, and satisfaction with the pharmacist’s friendliness. Next, respondents were asked to rate (on a scale ranging from 0 [not at all important] to 10 [extremely important]) the importance of the pharmacist’s knowledge, the pharmacist’s medication-taking advice, the pharmacist’s professionalism, the pharmacist’s friendliness, and the pharmacist’s visits. Finally, respondents were asked to rate (on a scale ranging from 0 [not at all useful] to 10 [extremely useful]) the usefulness of the pharmacist’s visits. A parallel written survey was distributed at the end of the pilot project to nurses and other home care professionals involved in caring for the patients who had participated in the project.
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Maintenance of Study DatabaseA study clerk maintained the project database by entering relevant information for each patient (e.g., demographic characteristics, number and types of medication-related issues and recommendations, number of recommendations accepted, and patient satisfaction scores). Each patient was assigned a study code to ensure that personal identifiers were not included in the project database. Data management and analyses were carried out with SPSS software, version 13.