SUMMARY
There is evidence that pharmacist integration into the general practice team may improve clinical and non-clinical outcomes.
Introduction
The healthcare needs of the community are becoming more complex. An increasing number of patients have multiple morbidities and require complex and intensive medical care.1 Complicated medicine regimens are being managed by multiple prescribers.2 Despite focused interventions designed to curb harms associated with medicine use, hospital admissions related to medicines were estimated to cost $1.2 billion in 2011–12.3 An Australian report found that up to 12% of people attending general practice had experienced an adverse drug event in the previous six months.3
The evidence
The majority of the
current evidence examining an integrated model of pharmacist and GP care is
positive. A recent systematic review and meta-analysis of pharmacist-delivered
services in general practice included 38 studies. Of these, 25 reported
positive effects on at least one primary outcome measure and 13 demonstrated no
effect.10 Interventions usually involved medication review, with or without
other activities delivered with the GP such as education, medication monitoring
and adjusting therapy. Four clinical markers were used to assess the effect of
interventions – blood pressure, glycosylated haemoglobin, cholesterol, and the
Framingham Risk Score. Results of the meta-analysis favoured the pharmacist
intervention with significant improvements observed in all clinical markers
compared to the control groups. Positive effects were more likely to be seen
with pharmacist-delivered multifaceted interventions in conjunction with
follow-up of patients compared to interventions that delivered a service in
isolation. There was limited or no effect on outcomes related to quality of
life, patient satisfaction, symptoms, and use of health service.
Individual studies have
shown improvements in other outcomes including:
- identification and reduction of medicine-related problems
- patient adherence to medicines
- process measures such as timeliness
- appropriateness of prescribing
- reduction in total number of medications.11-16
The transition of
patients with chronic and complex diseases from hospital to the community is a
critical time with an increased risk of medication misadventure and
re-hospitalisation.17 A UK study found that sending discharge letters to
practice pharmacists as well as GPs improved the coordination of care and
implementation of consultant recommendations for treatment.18
The large-scale PINCER trial found that a practice pharmacist-led intervention to reduce clinically important medicine-related problems was cost-effective.19 Australian studies have also reported cost savings ranging from $44–$100 per patient.20,21 A 2015 report commissioned by the Australian Medical Association and published by Deloitte Access Economics indicated that for every $1 invested, $1.56 in benefits could be generated. This equates to $544.87 million in savings over four years.22
The role of the practice pharmacist
Local studies have
determined the views of pharmacists, GPs and consumers on potential roles for a
practice pharmacist. Studies which detail the role of the practice pharmacist
in the intervention can also be considered.10,11,14,19,23,24
These roles can be
considered under three broad categories – patient-directed roles,
clinician-directed roles, and system- or practice-directed roles (Box).
A recent survey of Australian pharmacists6 found that 26 were working in or from a general practice medical centre. The most common services they undertook included comprehensive medication review, responding to clinical enquiries from GPs and responding to enquiries from other health professionals.
Funding practice pharmacists
A
number of potential barriers to integrating pharmacists into general practice
have been highlighted – namely a lack of remuneration and ‘turf wars’.23,24 The
latter appears to be a perceived and not a realised barrier given the support
for this model by both medical and pharmacy organisations. The absence of
dedicated and sustainable funding to facilitate pharmacist integration
continues to be the biggest barrier to implementation.
At a time of healthcare
funding review and reform, careful consideration is required by funding bodies,
policy makers and the pharmacy profession when examining models of
remuneration. Various funding models have been suggested7,25,26 which need to
be pragmatically considered in tandem with current health policy reforms. If
the services by practice pharmacists are to be flexible, a flexible funding
model is needed. A rigid model, such as fee-for-service may not allow services
to be customised to the specific needs of the medical centre and the community.
A blended funding model, in which payment for services undertaken by the
practice pharmacist is calculated and remunerated in a variety of ways from
government and private payers, could be explored.27 These hybrid models are
used to address shortcomings associated with single-based funding models.28 Many
other allied health professional services delivered through general practice
are funded via private sources such as private health insurers and patient
contributions. Importantly, whichever funding model is implemented, appropriate
governance and methods of reviewing the use of funds should be established and
enforced.
What does this mean for community pharmacists?
A practice pharmacist
has the potential to reduce fragmentation of care, improve medication
management and improve communication between GPs and pharmacists working within
community pharmacies. Medication reconciliation is a critical process to reduce
medication errors on transfer of patients from hospital back to the home or
residential aged care. Creating an accurate medication list for the patient is
beneficial to the patient’s usual GP as well as community pharmacists,
especially when packing dose administration aids.26 A practice pharmacist can
also be a link to existing community pharmacy services. Patients will benefit
from improved liaison between community pharmacists and GPs.
What needs to be done beyond remuneration?
General practice-based pharmacists may need to apply different skills compared to many pharmacists working in other settings. The Advanced Pharmacy Practice Framework for Australia supports the recognition of pharmacists with skills and experience for the practice pharmacist role.29
The introduction of the practice pharmacist within a complex and challenging health system may have some associated risks, whether these are fiscal, clinical, or otherwise. Evaluation and clinical governance of services to patients and the practice as a whole should be established from the outset and considered from a variety of perspectives.
Conclusion
The primary purpose of a
practice pharmacist would be to support GPs to minimise the risks associated
with medicines and optimise patient outcomes through the quality use of
medicines. Integrating pharmacists into general practice would reduce
fragmentation of care and medication misadventure using the distinctive
knowledge and skills of pharmacists. Collaborative medication management
between the GP and the pharmacist could reduce costs to the health system from
adverse drug events and sub-optimal adherence to medication regimens. Funding
models need to be further investigated to ensure cost-effectiveness of flexible
models of care.
Christopher Freeman is
a Director at the Pharmaceutical Society of Australia and the Australian
Association of Consultant Pharmacy.
Deborah Rigby is a
member of the Board of Directors of NPS MedicineWise.
References
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- Morgan TK, Williamson M, Pirotta M, Stewart K, Myers SP, Barnes J. A national census of medicines use: a 24-hour snapshot of Australians aged 50 years and older. Med J Aust 2012;196:50-3.
- Roughead L, Semple S, Rosenfeld E. Literature review: medication safety in Australia. Sydney: Australian Commission on Safety and Quality in Health Care; 2013.
- The Royal Australian College of General Practitioners. Vision for general practice and a sustainable healthcare system. Melbourne: RACGP; 2015.
- Ackermann E, Douglas Williams I, Freeman C. Pharmacists in general practice--a proposed role in the multidisciplinary team. Aust Fam Physician 2010;39:163-4.
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- Australian Council on Safety and Quality in Health Care. Second national report on improving patient safety: improving medication safety. Canberra: Australian Council on Safety and Quality in Health Care; 2002.
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- Hanna M, Larmour I, Wilson S, O'Leary K. Patient and general practitioner perspectives of the Hospital Outreach Medication Review service at Monash Health. J Pharm Pract Res 2015;45:282-90.
- The Society of Hospital Pharmacists of Australia. SHPA’s vision for practice-based pharmacists. Melbourne: SHPA; 2015.
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