Medication-Related Issues and Pharmacist Recommendations

Over the 5 visits, a total of 98 medication-related issues were identified, an average of 3.6 (SD 2.0) per patient. More than half of these medication-related issues (52 or 53%) were identified at visit 1, a quarter (25 or 26%) were identified at visit 2, and 15 (15%) were identified at visit 3. The reduction from visit 1 to visit 2 was statistically significant (pairwise t24 = 2.22, p = 0.036), but the change from visit 2 to visit 3 was not (pairwise t21 = 1.25, p = 0.24). Although the number of patients declined to 7 for visit 4 and 3 for visit 5, a further 3 medication-related issues (3% of the total number) were identified at each of visits 4 and 5. The most common medication-related issues were linked to failure to receive a medication, untreated indications, and incorrect doses (subtherapeutic dose or overdose combined) (Table 3). In response to these medication-related issues, a total of 116 recommendations were made by the pharmacist, an average of 4.3 (SD 2.6) per patient. There was a trend toward a decrease from visit 1 (mean 2.3 per patient, SD 2.0) to visit 2 (mean 1.3, SD 1.3) (pairwise t2i = 1.85, p = 0.08), as well as a trend toward a decrease from visit 2 to visit 3 (mean = 0.7, SD 1.0) (pairwise t21 = 1.95, p = 0.07). The number of recommendations and their significance across the entire study is shown in Figure 2. Of the 116 recommendations made, 53 (46%) were directed toward the physician, 52 (45%) were directed to the patient or caregiver, and 11 (9%) were directed to nurses. Table 4 shows the distribution of recommendations that were accepted over the course of the study.

Fifty-one (44%) of the 116 recommendations were related to altering specific medications (i.e., starting a medication, discontinuing a medication, changing a medication, or changing a medication dose or instructions). Recommendations related to laboratory or symptom monitoring accounted for 28 (24%) of the recommendations, 14 (12%) of the recommendations relat­ed to adherence, and 12 (10%) of the recommendations were educational in nature (to the patient and/or caregiver).
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Table 3. Medication-Related Issues Identified across Visits



No. of Issues Identified



Category



Visit


1



Visit 2



Visit


3



Visit


4



Visit


5



Total

Failure to
receive needed medication

15


6

2


0


1

24

Untreated
indication

13

5

2




1


0


21

Adverse
drug reaction


6

3

4


0


0

13


Subtherapeutic dose

4


1

3

2


0


10

Overdose

3

5


1


0


0

9

Drug
interaction

4


1

3


0


1

9

Improper
drug selection

3

3


0


0


0


6

Drug use
without an indication


0


0


0


0


0


0

Other

4


1


0


0


1


6

Total

52

25

15

3

3

98

Each recommendation was rated in terms of its clinical significance. The majority of recommenda­tions (83 [71%] of the 116 recommendations) were rated as significant (level 4). Examples of such “significant” recommendations included starting a 6-blocker for a patient with a history of myocardial infarction or starting an angiotensin-converting enzyme inhibitor for a patient with heart failure. Twenty (17%) of the 116 recommendations were rated as very significant (level 5) and 13 (11%) of recommendations were rated as somewhat significant (level 3). The average numeric rating of significance of the recommendations was 4.1 (SD 0.3). The distribution of recommendations at each level of significance over the course of the study is shown in Figure 2. eriacta tablets

Table 4. Recommendations and Acceptance Rate over Time







No. of Issues Identified







Recommendation



Visit

1



Visit

2



Visit

3







Visit 4



Visit

5



Total

(%)*





To physician


Accepted


20


12


3


3


1


39 (74)


Rejected or unknown


3


4


5


0


2


14+


Total


23


16


8


3


3


53





To nurse


Accepted


8


1


2


0


0


11 (100)


Rejected or unknown


0


0


0


0


0


0


Total


8


1


2


0


0


11





To patient or caregiver


Accepted


22


12


3


0


0


37 (71)


Rejected or unknown


8


4


2


1


0


15


Total


30


16


5


1


0


52


*Percentage in relation
to total number of recommendations of each type.



+A total of
3 (6%) of
recommendations to physicians were rejected, and the outcome of

11 (21%)
was unknown.

Even with the small number of patients included in this pilot project, a large number of medication-related issues was identified over a short period, and more than 100 recommendations were made by the pharmacist. More important, most of the recommendations were clin­ically significant, and most were accepted by those to whom they were directed, particularly other members of the health care team.

Satisfaction Ratings

Once patients completed the pilot project, they (or their caregivers) were asked to rate their satisfaction with pharmacy services. Sixteen patients responded to the telephone survey. All of these patients were overwhelmingly positive about the inclusion of pharmacy services as part of their home care, and no rating on any of the questions was lower than 8 out of 10. Indeed, for overall satisfaction, the mean rating was 9.9 (SD = 0.5). Patients were also clear about the importance of the home visits (mean rating of importance 9.8, SD 0.5) and their usefulness (mean rating of usefulness 9.5, SD = 0.8).
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Figure 2. Number of recommendations

Figure 2. Number of recommendations made and their signif­icance ratings for successive visits. M rating = mean rating.

Parallel surveys were also distributed in hard copy to the nurses and other allied health care professionals involved in the pilot project; 14 nurses and 4 other health care professionals responded to the survey (although some of the non-nurse respondents did not answer all questions). Again, the respondents reported very high satisfaction ratings: no rating was less than 7 on the 10-point scale, and the mean rating was 9.5 or higher for each question. Mean ratings for key variables were as follows: overall satisfaction with the pharmacist’s services, mean 9.5, SD = 0.9 (n = 17); importance of the visits, mean 9.6, SD = 0.6 (n = 17); and usefulness of the visits, mean 9.9, SD = 0.3 (n = 16). Respondents were also given the opportunity to provide comments; most of these addressed the need to continue the provision of pharmacy services beyond this pilot project. cialis canadian pharmacy