PRUEBAS DE ACEPTACIÓN

There have been previous studies involving community pharmacist in repeat prescription review. What makes this study unique is the study design, in that the absolute effect of having a pharmacist to review repeat prescriptions was measured. Taking the GP’s agreement of the interventions into account, the community pharmacist reduced the

absolute risk of a DRP by 26%. For every 3.8 repeat prescription reviewed by the community pharmacist, a DRP was prevented.

Some patients were reviewed and intervened on more than one occasion. The repeated review of the same patients was studied through comparing the intervention ratio for the consecutive review occasions. Surprisingly, this was stable. One would expect the intervention ratio to drop with repeated reviews of the same patient’s repeat prescription. It would perhaps be expected that patients who already had DRPs resolved with their repeat prescription, would not have new DRPs emerging. Since this was not the case, the findings highlight the need for regular repeat prescription review, and not just a one-off service. In addition, with 55.1% of the patients receiving pharmaceutical intervention at some point, this is evidence for the need for continuous repeat prescription review. Possible reasons for the stable intervention ratio can be that patients receiving repeat prescriptions are not as static as the repeat prescription system requires. Patients’ compliance is known to vary (Morris and Schulz, 1992), they hoard, or take less or more than is prescribed (Law and Chalmers, 1976), they go to hospital where medicines are stopped or initiated, and the information is not satisfactory transferred back to their regular GP (Duggan et al, 1996), or the regimens are excessively complex (Walley and Scott, 1995).

The overall agreement and actioning ratio was 0.77 and is similar to the actioning ratio of 0.69 found by Sykes et at (1996), but considerable higher than the 0.32 found by Goldstein

et al (1998). This may be due to the design of the study where the GP and the pharmacist had regular meetings where they developed a working relationship over time compared to short term, key message, projects. The overall prescription intervention rate of 0.37 and the actioning ratio of 0.77 argue that the pharmacist identified relevant DRPs that were also actioned in practice.

The DRPs were identified over a wide range of BNF categories and reveals the potential for a community pharmacist to intervene over a wide range of drugs and therapeutic areas in co-operation with the GP, previously considered beyond the boundaries of the profession

(Bradshaw and Doucette, 1998; Harding and Taylor, 1990; Jepson and Strickland-Hodge, 1995; Paes, 1983; Spencer and Edwards, 1992).

5.10.2.1 Discussion of the categories of DRPs

Almost half of the DRPs were connected to medicines removed from the repeat prescription. With computers and software installed to ease the work and increase the quality of repeat prescribing, they have also created new problems with over-prescribing. However trivial this DRP may seem, some clarification of what medicines the patients are, or should be, taking must be included as part of a vital quality assurance. The high frequency of medicines offered that are no longer taken serve as an indicator both to the lack of regular review as well as a reflection of unused medicines returned to pharmacies every year. In addition, request-forms with repeat medicines no longer used must be confusing for the patients, as they are offered to re-order medicines they are told to stop.

The secondly most frequent DRPs were regarding dose alterations (14.4%). These were seen as interventions of therapeutic importance improving the quality of the prescribing and reducing the risk of side effects for the patients.

The need for monitoring and counselling (10.9%) highlighted that it was often unclear from the medical notes, the prescribed medication and the computer records what the patient was taking. Calling the patient in for counselling was an attempt to clarify why the patient had stopped the medication, why they had long intervals of not ordering the medication for then to start again and for introducing the patient to new medication.

Double supply (6.5%) of the same drug also caused concern and highlighted poor review routines. However, whether or not a patient used both supplies could not be revealed through this ‘paper based’ review process. The ‘pharmaceutical’ interventions changing the quantity to fit the dose (1.1%) or suggesting other formulations or routes of administration (3.3%) were not as frequent, but still important from a compliance point of view. The failure to adjust quantities to match the dose was reported as a problem in 1973

(Anonymous, 1973) and was addressed in a larger study by Rees et al (1993). Synchronising the number of day’s treatment for each prescription item should lead to increased compliance.

Drug-related problems related to poor prescribing or contraindication (7.1%) produced much heated debate between the pharmacist and the GP as to whether they were clinically significant or not. This, together with dose alterations, were the most fruitful of categories to discuss. This was because these are areas where the GP felt that he is the expert and not used to being questioned on the quality and the safety of prescribing. The problem of confidence among pharmacists in their own knowledge and competence in discussing practice matters with GPs was discussed by Blenkinsopp et al (1993). However, Home (1993) found that a closer collaboration with prescribers will ensure that the medical regimes reflect patients’ individual need. Han and Sorofman (1996) also argue that the future course of pharmacy will be to manage the shift from product-oriented pharmacy to patient-oriented pharmacy.