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Review Article Community Pharmacist and General Practitioner Collaborated Services - A Review Jaidev Kumar, Kotyal Basvannappa Mahendrappa*, Pramod Kumar, U. R. Rakshith

ABSTRACT

Home review (HMR) services were specifically created to assist elderly patients residing in their homes to have more benefits of medication regimen that can help them in understanding the importance of medications through medication review by community pharmacist and HMR services were rendered with the intention of minimizing medication-related problems. The successful operation of HMR depends on good coordination between patients, general practitioner (GP), and accredited pharmacist. In some circumstances, other health-care team members such as nurses in community practice can also play an important role in ensuring whether patient is following correct administration guidelines of or not. The common screening of medications carried out by community pharmacist was reflected with checking rationality of drug, over the counter medicinal products, patient medication adherence, drug monitoring whether signs and symptoms are minimized or subsided. If drug-related problems were identified they were communicated to concerned patient through HMR report and requested to make certain changes in drug therapy management in according to severity of drug- related problem.

KEY WORDS: Home, Medicine, Review

INTRODUCTION improved medication adherence due to comprehensive pharmaceutical care services provided during HMR One of the research investigator named Urbis Keys study. Young 2005 showed that the application of home medicines review (HMR) services was responsible ADHERENCE/COMPLIANCE/ for bringing down the number of hospital admissions which was reflected by HMR data of patients. Another CONCORDANCE research study known as VALMER study (Stafford) The medication adherence during randomized which was carried out in 2012 reflected that HMR controlled trial of HMR in was assessed with was responsible or influential in bringing down the application of two self-administered questionnaires. duration of hospital stay during 1 year and enabled to The findings of medication adherence among test and resolve the identified drug-related problems (DRPs) control group did not show any significant difference by pharmacists. Older HMR research studies carried and reflected overall high levels of adherence rate at out in Australia, UK, , etc., have clearly reflected that pharmacist can play an important role all-time follow-up of patients in both groups. HMR in minimizing DRPs among patients prescribed research studies that were carried out in medication with polypharmacy. HMR services received among adherence showed that good progress in medication patients with complicated medical problems have adherence did not mean that it can have impact on health shown that pharmacist can play important role in outcomes of patients. Therefore, assessing medication minimizing drug-induced hospitalization followed by adherence with respect to medical conditions does mean that there is only clinical endpoint outcome. The Access this article online concrete evidence regarding medication adherence of HMR is lacking due to inadequate research duration Website: jprsolutions.info ISSN: 0975-7619 and less sample size.

Department of Paediatric, JSS Medical College and Hospital (Affiliated to JSS Academy of Higher Education and Research), Mysore, Karnataka, India

*Corresponding author: Dr. Kotyal Basvannappa Mahendrappa, Department of Paediatric, JSS Medical College and Hospital (Affiliated to JSS Academy of Higher Education and Research), SS. Nagar, Mysore - 570 015, Karnataka, India. Mobile: +91-9448026099. E-mail: [email protected]

Received on: 07-10-2019; Revised on: 11-11-2019; Accepted on: 14-12-2019

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COORDINATION AMONG the research author suggests that frequent medication HEALTH-CARE TEAM reviews on ederly patients by research pharmacists can help in overcoming medication abuse. Implementation MEMBERS and evaluation of therapeutic guidelines will help in minimizing the inappropriate use of medications To achieve better patient health welfare good [5] coordination among health-care team members are among elderly patients. required, so health-care outcomes will be successful. A clinical trial study by Bernal et al. suggests that Patients who are recently discharged from hospital following therapeutic guidelines (i.e., antithrombotic, can find more benefits by HMR services as per the [1] Beta-blockers, angiotensin-converting enzyme recommendations of Campbell research study. inhibitors, and statins) applied in the management of Lee et al. reflected in their research study that New coronary syndrome (ACS) have shown better [6] Zealand Pharmacists have provided medication prognosis. Research author also states that ACS reviews for selected patients for almost two decades patients have reflected further progression of by working with patient consultant for providing better and increased mortality rate due to inappropriate use health-care services that help to establish good rapport of medications. According to research author, one between patient and pharmacist.[2] Pharmaceutical of the important problems reflected in this study review services were government-funded in New was premature discontinuation of the medications Zealand where patient needs not bear any medication and non-adherence to medications in patients with expenses, whereas comprehensive pharmaceutical care ACS can lead to more health-care problems due to is not a government-funded health-care services and further progression of disease. Therefore, to overcome patient must bear medical expenses by themselves.[2] medication-related problem regular medication review by pharmacists in post-discharged patients with ACS Residential Medication Management Review can improve patient prognosis.[6] (RMMR) guidelines are the one which support the quality use of medicines, i.e., safe and effective use Holland et al. have reported that older people are often of medicines in respective medical conditions and acquired by multiple for which they receive medication review services for aged patients with the multiple medications that can lead to complexities and assistance of accredited pharmacists.[3] Establishing drug toxicities which can be overcome by pharmacist this type of RMMR guidelines for residential aged medication review among these older patients. The patients in Australian study have reflected improved research carried out by pharmacist-led medication health-care outcomes.[3] review interventions should be based on the identified DRPs and assess whether medications were Turner and Bell research study reflected that medication responsible for hospitalization or mortality rate among review carried out by the health-care team consisting older patients. This research study finally concludes of pharmacists and general medical practitioners is a that pharmacist-led interventions in older patients broader investigated concept to get the most utility of may improve drug knowledge and drug adherence but medications. According to findings of research, author lack of information reveals that whether the patient different health-care benefits such as minimizing the quality of life was influenced positively on health-care adverse drug events (ADEs), physical verification of outcomes of older patients?[7] storage, and expiry date of medication, and compilation of medication list comprising of prescribed and non- Rigby suggests that role of pharmacists is broadening prescribed medications. The author finally concludes in primary health-care services. According to that ADEs are more in elderly patients due to age- this author, success in primary health care can be related pharmacokinetic changes, but the occurrence obtained with good coordination among health-care [8] of ADEs can be minimized by conducting more HMR professionals. A literature review by the national programs in the future in according to the clinical prescribing service of Australia has been able to situation of medical case.[4] identify more DRPs during medication misadventure which accounts nearly 6% of hospitalization due to Gowan and Roller study reflects elder drug abuse ADEs when it was compared with other categories mean misusing drugs such as deliberate consumption of medication errors such as underdose, overdose, of excessive quantity of the drug or not following and failure to receive medication. The important correct directions of drug usage.[5] Elderly abuse can reason behind influence of medication errors was poor occur in all cultures crosswise across all social and communication among the health-care professionals. economic classes due to imbalance thoughts of power. Research author suggests that medication-related Elderly patients suffering from chronic medical problems can be overcome with good coordination conditions can end up with poor prognosis due to among health-care professionals, i.e., doctors, nurses, multiple medications of irrational drug use. Therefore, and pharmacists.[8]

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Zermansky et al. have said that elderly people are often electronic database as separate tool to monitor DRPs weak due to aging factor and can have progressive for clinical management of patients. The electronic degenerative health problems.[9] Increased risk of database tool allowed the pharmacist to follow the ADEs is attributed to multiple medications in elderly patient to track individual patient progress by entering patients. Elderly patients often relying on health- drug therapy information and retrieving those problems care takers and with frequent psychiatric problems that had not been resolved, those which had not been underestimate their individual ability to report adverse solved will be conveyed to patient consultant to take drug reaction clinical manifestations. The author action in according to severity of DRPs.[10] suggests that clinical medication review should be conducted by research pharmacist within 28 days of Hussainy et al. tells that service is a randomization. To gather medical case history data service where it is meant to cure the but does of patient following resources are utilized for clinical not cure the illness.[11] Research statistics reveals medication review such as GP clinical record, interview that approximately 50–90.5% of cancer patients and with the patient, and health-care taker. The findings 9–16% of non-cancer patients were referred into of the medication reviews and recommendations for palliative care services per 1 lakh population per year clinical medication review should be conveyed by the in Australia. Palliative care services were provided in pharmacist through a written pro forma to the GP for three types of health-care settings such as community, acceptance and implementation of the same.[9] selected palliative care, or hospice facilities (hospital meant for dying patients) and within acute care Fletcher et al. research study carried out by both hospitals. Patients opting home as the most common pharmacist and nurse to evaluate the use of medication setting where approximately 70–80% of patients appropriateness in elderly patients of Canadian receive palliative care with a significant proportion population.[10] The research design applied in this choosing to end life at home. A common problem research study was randomized controlled trial. reflected in the home is inability to sufficiently Patients enrolled in this research study were from manage medications due to poor literacy status of a single publicly funded family health network patients or ignore to take care of patients by family practice of eight family and associated health-care takers which are often seen in patients staff serving 10,000 patients in a rural area near suffering from pain. This usually occurs due to poor Ottawa, which is located in Canada. Family physicians understanding and knowledge about medications and considered elderly patients aged 50 years or older as lack of health literacy in the palliative care population. they are at more risk of experiencing adverse drug The palliative care population has been identified reactions due to age-related pharmacokinetic and as one of the groups who are at increased risk of pharmacodynamics changes. A pharmacist or one of medication misuse leading to ADEs and consequently three nurse practitioners visited each patient at his or drug-induced hospitalization.[11] her home and conducted comprehensive medication review and developed tailored plan to optimize the Ahmad et al. defines that DRPs are events or medication use. The optimized medication use plan circumstances involving drug therapy that actually was developed in consultation with the patient and the or potentially interfering with patient experiencing patient’s consultant. The medication appropriateness optimum outcome of medical problems/anticipated index was applied in this research study to identify the health outcomes.[12] DRPs may be associated with rational use of medications among elderly patients. The contraindication, drug given without indication, author investigated the relationship between personal interactions, ADR, and inefficacy of treatment. The characteristics and inappropriate use at baseline and contributing factors for these DRPs can be prescription with improvements in medication use at the follow- errors, patients not following the correct instructions up assessments. Pharmacist and nurse documented all given by Registered Medical Practitioners. Factors drug-related problems encountered during the clinical that increases the risk of DRPs are more than five trial. The medication appropriateness index was drugs in a prescription, increased comorbidities such applied to evaluate the prescriptions of medications. as hypertension, mellitus, and asthma, age It has been reflected that medication appropriateness progressing, and lack of medications understanding index has found to be proven as reliable, valid among treating physicians. Prescribing more number measure of appropriateness of prescribing. This of drugs in a prescription increases the risk of research study provides information only about DRPs. Researcher Runciman found a relationship clinical appropriateness of prescribed medication in between increased medication use has resulted each patient but pharmacoeconomic component was hospitalization due to ADRs. Research review studies missing. The author clearly suggests that they were have reflected that health status in elderly people has more interested in knowing rational use of medications shown that multiple drug use is a strong predictor applying medication appropriateness index rather than of hospitalizations, , hypoglycemia, fractures, cost component of medication. The pharmacist utilized impaired mobility, pneumonia, and malnutrition.[12]

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CONCLUSION 2. Lee E, Braund R, Tordoff J. Examining the first year of medicines use review services provided by pharmacists in New HMR research studies are carried out in Australia, . N Z Med J 2009;122:3566. 3. Pharmaceutical Society of Australia. Guidelines for Zealand, , Canada, etc., where it has Pharmacists Providing Residential Medication Management reflected that elderly patients with poor literacy rate Review (RMMR) and Quality Use of Medicines (QUM) have difficulty in managing medications, due to older Services. Canberra: Pharmaceutical Society of Australia; 2011. age among elderly patients have decreased hepatic p. 1-23. 4. Turner JP, Bell JS. Implementation of pharmacist-led and renal function which can induce more adverse medication reviews in general practice. Int J Clin Pharm drug reactions as most of the drugs will undergo 2013;35:3-4. metabolism through hepatic route and excreted through 5. Gowan J, Roller L. Elder abuse medication reviews and the renal route. Each and every medication received by pharmacist. Aust J Pharm 2009;90:67. 6. Bernal DD, Stafford L, Bereznicki LR, Castelino RL, elderly patients should be screened for hepatic and Davidson PM, Peterson GM. Home medicines reviews renal dosage adjustment according to hepatic and following acute coronary syndrome: Study protocol for a renal function status. Pharmacist intervention among randomized controlled trial. Trials 2012;13:30. all these research studies have reflected that if any 7. Holland R, Desborough J, Goodyer L, Hall S, Wright D, Loke YK. Does pharmacist-led medication review help to identified medication errors were seen that can be reduce hospital admissions and in older people? A overcome by adopting the proper strategy and any systematic review and meta-analysis. Br J Clin Pharmacol identified DRPs problems were found can be resolved 2008;65:303-16. 8. Rigby D. Collaboration between doctors and pharmacists in the with proper strategies. The priority given for patients to community. Aust Prescr 2010;33:191-3. be enrolled for HMR should be cognitive impairment 9. Zermansky AG, Alldred DP, Petty DR, Raynor DK, followed by elderly patients with poor literacy status Freemantle N, Eastaugh J, et al. Clinical medication review by a and no health-care takers, any patient suffering from pharmacist of elderly people living in care homes--randomised controlled trial. Age Ageing 2006;35:586-91. complicated medical conditions, prescribed with 10. Fletcher J, Hogg W, Farrell B, Woodend K, Dahrouge S, multiple medications and more comorbidities which Lemelin J, et al. Effect of and pharmacist was observed among all these older research studies. counseling on inappropriate medication use in family practice. Common conclusive evidence found among all these Can Fam 2012;58:862-8. 11. Hussainy SY, Box M, Scholes S. Piloting the role of a research studies were that pharmacist intervention pharmacist in a community palliative care multidisciplinary can improve medication adherence followed by drug- team: An Australian experience. BMC Palliat Care 2011;10:16. induced hospitalization can be prevented with the help 12. Ahmad A, Hugtenburg J, Welschen LM, Dekker JM, Nijpels G. of pharmacist intervention. Effect of medication review and cognitive behaviour treatment by community pharmacists of patients discharged from the hospital on drug related problems and compliance: Design of a REFERENCES randomized controlled trial. BMC 2010;10:133. 1. Available from: https://www.medicareaustralia.gov.au/ provider/pbs/fifth-agreement/home-medicinesreview.jsp. [Last Source of support: Nil; Conflicts of interest: None Declared accessed on 2013 Dec 16].

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