Issue 45 / 25 November 2013

THE ongoing bid by pharmacists to expand their primary health care role has been struck a blow by US research showing no health benefits from a pharmacy-led medication adherence intervention.

“Unfortunately this adds to the ongoing evidence that these types of pharmacy interventions have no positive health impacts”, Dr Evan Ackermann, chair of the Royal Australian College of General Practitioners’ National Standing Committee for Quality Care, told MJA InSight.

The research, published in JAMA Internal Medicine, randomly assigned 241 acute coronary syndrome (ACS) patients from four medical centres in the US to either the intervention group (n = 122) or usual care (n = 119). (1)

The intervention, which lasted 1 year after hospital discharge, included pharmacist-led medication reconciliation and tailoring; patient education; collaborative care between the pharmacist and the patient’s primary care clinician and/or cardiologist; and voice messaging (educational and medication refill reminder calls).

Although the results showed that 89.3% of those in the intervention group were adherent compared with 73.9% in the usual care group, there was no significant improvement in the proportion of patients who achieved blood pressure and low-density lipoprotein cholesterol level goals.

Dr Ackermann said there was no evidence to support medication interventions in primary care, or for medication reconciliation by a pharmacist at hospital admission or discharge.

“Systematic reviews undertaken by the National Prescribing Service (NPS) and other high-quality reviews consistently fail to find benefit from this type of intervention”, he said. (2), (3)

Dr Ackermann said further research should focus specifically on issues raised by the NPS review.

He called for research priority to be given to medication safety interventions in diseases where medication was an important part of care and where patients were prone to high hospital admission rates (eg, heart failure), the use of drugs associated with a high risk of adverse events, and high-risk settings such as aged care facilities and transfer of care.

He said evidence about the factors contributing to adverse drug events should be used to develop strategies that improved early detection and prevention of adverse drug events.

“I believe this can only occur within the confines of a general practice, using pharmacy funding schemes that do not rely on the sale of medications”, Dr Ackermann said.

An editorial in JAMA Internal Medicine predicted that if the studied intervention were applied to every patient with ACS in the US it “would add $1 billion annually to health care costs”. (4)

“The relatively modest increases in already high rates of medication regimen adherence in the patients studied may not translate into improved outcomes even if maintained for 3 to 5 years or longer”, the author wrote.

Before recommending investment in this strategy, “it would be prudent to know that patient outcomes will actually improve”.

Andrew Matthews, national director for quality assurance and standards at the Pharmacy Guild, said that as medicines experts, pharmacists considered improving medicine adherence as a key role of their profession.

Mr Matthews said the JAMA Internal Medicine research was consistent with other research showing improvement in patient outcomes associated with higher levels of adherence.

“The Guild sees this as further evidence supporting the expansion of pharmacists’ primary health care role”, he said.

1. JAMA Intern Med 2013; Online 18 November
2. National Prescribing Service 2009; Medication safety in the community
3. Br J Clin Pharmacol 2008; 65: 303-316
4. JAMA Intern Med 2013; Online 18 November


Poll

Should pharmacists have a funded role in improving medication adherence by patients?
  • Yes (61%, 132 Votes)
  • No (30%, 64 Votes)
  • Maybe (9%, 20 Votes)

Total Voters: 216

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14 thoughts on “No benefit in pharmacist intervention

  1. Judith O'Malley-Ford says:

    “chenists” are not doctors, end of story.

  2. Dr alan mclean says:

    Notwithstanding  the studies I still feel there could be value in highly specific pharmacy programs eg Insulin adherence and BSL or Warfarin and INR. The double benefit with applied interventions such as these could be that there is a short term patient safety benefit as well as a long term risk reduction. Any drug with [1] a significant risk profile and [2] a short term target measurable at the pharmacy could be involved. This could be especially applicable to rural pharmacies and in particular where the medical practice is stressed by patient load.

  3. Andrew Crawford says:

    We probably also should bear in mind that my patients tell me that pharmacy is changing, at least in the city.  The known and trusted, bearded and friendly pharmacist (see photo in story) is a dying breed, now there are employee new graduates rostered between the many outlets of a corporate pharmacy chain.  I doubt that these pharmacists are given the KPIs or the time to form relationships with their patients, on the other hand I see little doubt that the corporate owners are well aware of the potential revenue stream from medication review programmes and the like.  There is a significant vested interest here, and we can no longer rely so much on the professionalism of that trusted, bearded pharmacist to keep those interests in check.

  4. Ray Skinner says:

    Contra to the Insights’ comments, the study does not disprove the benefit of pharmacist extended services and interventions.

    What the data suggest is that, in this particular condition, formal improvement of the adherence to the standard medication regimen is not associated with significant outcome gains. This result stands, no matter who carried out the interventions. It happened to be pharmacists, but it could have been nurses, patient educators, or even Doctors! The result itself is counter-intuitive, and shows the real value of research in validating what we should be doing to improve health outcomes.

    More importantly, perhaps, it reveals something else that is somewhat counter-intuitive; it shows that less than 75% adherence is quite sufficient to gain the same broad benefit. Quite clearly, then the prescribing for outcomes in this condition needs to be reviewed, as this study clearly indicates we might be wasting >25% of the budget spent on these medications for no real health gain.

    What else does the study really do? It helps to re-set priorities, and it contributes positively to knowing where skilled pharmaceutical intervention might, or (as in this case, might not) best be utlised. This is just the beginning of a whole raft of possiblities. As Dr McLean suggests, there may well be areas where such interventions do produce better outcomes – but who knows unless we do more of this kind of research?

    Bottom line; more research in this area, not mere Pharmacist-bashing to hinder the proper use of skilled pharmaceutical support for patients.

     

  5. John Geo says:

    Recent reviews including Cochrane Reviews support pharmacist roles in primary and secondary care settings: http://www.ncbi.nlm.nih.gov/pubmed/20614422 http://www.ncbi.nlm.nih.gov/pubmed/23450614                                                                                         

    It seems like Dr Ackerman has changed his stance still publishing a commentary in RACGP supporting collaborative efforts with pharmacists. http://www.racgp.org.au/download/documents/AFP/2010/March/201003ackermann.pdf

  6. Phil Day says:

    Wrt “Dr Ackermann said there was no evidence to support medication interventions in primary care, or for medication reconciliation by a pharmacist at hospital admission or discharge.”

    I am a Hospital Pharmacist working in a suburban Public Hospital in Australia. Much of our time is spent doing medication reconciliation for patients on the ward. The amount of medication that is not correctly transcribed  or obtained esp. by Junior Doctors would be around 20% IMHO. 

    So if you want your patients to receive 20% of their medications as randomly incorrect, then dispense with our services. Often I feel like Sherlock Holmes trying to get to the truth of what a patient really takes. Takes times & effort, phoning GP’s, local Pharmacies, Nursing Homes, relatives for this information.

    We are not trying to be Doctors here – just improve quality use of medications.

    Methinks Ackermann has a poor opinion of the benefits of Pharmacists in a Hospital Ward. I wonder why. The evidence is not there.

     

     

  7. John George says:

    I wish the critiques of pharmacist interventions, including the editor of MJA Insight and Dr Ackerman, had read the Jama paper more closely before they started pharmacist bashing. The Jama paper achieved its primary objective. The study was not powered and was not long enough to demonstrate some of the secondary or tertiary outcomes. Moreover, the intervention was multidisciplinary, not a pharmacist only intervention. It is like blaming the captain for losing the match.

    hope people like dr Ackerman will be a bit more responsible when making such comments, which has implications on the professional relationships between pharmacists and doctors in various settings across the country. Give a more balanced opinion based on overall evidence.

    Don’t throw the baby out with the bath water!

  8. Jarord McMaugh says:

    If adherence improves, but outcomes do not, this is a failure of the clinician (ie the doctor), not the counsellor (in this case, the pharmacist).

    If patient compliance improves but measurable outcomes do not, this means the doctor is either failing to adjust treatment as approporiate to symptoms, or is failing to follow up with the patient in a timely manner to make the observations needed to make these changes.

     

    And as pointed out above, who acts as the counsellor in these situations is not relevant to the outcome. Pharmacists’ primary role is to counsell patients and ensure quality use of medicines, but any health professional can assist with this role – certainly doctors should be doing this but it’s not uncommon to have patients who have had no counselling from their doctor at all.

    Interesting results, flawed conclusion.

  9. Warren Leonard says:

    “Chenists” are not doctors, end of story….. similarly, Doctors are not Pharmacists. Doctors are superb diagnosticians, however are not necessarily medicines experts. It would be interesting to discover how and where Doctors obtain their medicines education – from seminars sponsored by those who research and manufacture medicines?

     

  10. Erin Dunn says:

    How ridiculously simplistic to assume that secondary outcomes such as blood pressure and cholesterol determine whether adherence intervention is successful or not amongst a group of 250 patients. The trial endeavoured to determine whether adherence improved with pharmacist intervention. It achieved this. The trial wasn’t powered to detect clinically significant differences in blood pressure and cholesterol and if it was, who cares? What we really want to know is, does this improved adherence translate into reduced morbidity and mortality? Certainly promising results such as these warrant further research to answer these questions, rather than condescending, agenda-driven commentary. 

  11. Kate Callaghan says:

    Sweeping statements lacking full references, misrepresentation of results and a sensationalist headline…Is the MJA really supporting such shoddy journalism?

    One quick read through the original publication in JAMA shows that a multifaceted, pharmacist-led intervention is found to increase adherence with a post-ACS medication regimen. These results are in spite of factors that will have led to a more conservative estimate, such as underpowered study design (too small a sample to reach 80% power, thus increased risk of type II error). The sample population also had relatively high levels of adherence in the first place (74% adherence in control group), which leaves less room to demonstrate improvement. A well-powered interventional RCA that samples those most prone to non-adherence would surely demonstrate a larger effect size that may translate into a significant clinical effect. 

    Why the focus on clinical outcomes when we know that these biomarkers are affected by a large constellation of factors well beyond the study scope? Are we supposed to forget the overwhelmingly conclusive body of evidence that already demonstrates the link between increased adherence and improved morbidity and mortality? Given the modern climate of google doctor and faux naturalism, surely any intervention that improves the proportion of a population that are adherent to their post-ACS medications ought to be considered a win?

    All this MJA InSight article demonstrates is a concerning lack of skill (or perhaps care) in the art of critically analysing published works and reporting their results in a way that is both practical and credible.

  12. Department of Health Victoria Clinicians Health Channel says:

    Two different issues:

    1. 1. Pharmacists improve compliance = successful outcome to pharmacists
    2. 2. Improving compliance doesn’t improve outcomes = problem with treatment regimen – all they have proved is that it doesn’t matter if patients aren’t compliant, they still get the same benefit. 

    The study isn’t a slight against pharmacists, the interpretation provided is.

  13. John Woodward says:

    I would like to thank MJA Insight for publishing this article and especially for the discussion it generates.  This discussion is a fantastic avenue for enhancing the insight of those involved in primary (and secondary) health care as to how increased integration of clinical pharmacists within these practise settings improves patient outcomes.

    Earlier posts have mentioned the evidence supporting greater clinical pharmacist involvement in a variety of care settings so I would won’t rehash that in this post.

    What I will mention though is some of the feedback I get from GP’s regarding my practise as a consultant clinical pharmacist within general practice:

    “losing you would be a retrograde step to quality prescribing and the rational review of medications”

    “you are a learning resource for GPs at all levels of training & experience”

    The role clinical pharmacists are playing within general practice is expanding and this will benefit all (patients, doctors, nurses, students).   If the number of relevant skill sets around the patient care table increases, and provided the varying skills are integrated effectively, then the decisions that are made can only be optimised. 

    Be open and embrace the possibilities.

  14. CIAP - NSW Health says:

    This article draws parallels where there are none.

    “Unfortunately this adds to the ongoing evidence that these types of pharmacy interventions have no positive health impacts”. What are “these types” of interventions? Why are we drawing parallels between a study on the effectiveness of educating on the importance of compliance and other roles a pharmacist undertakes?

    “Dr Ackermann said there was no evidence to support medication interventions in primary care, or for medication reconciliation by a pharmacist at hospital admission or discharge.”

    Why would you expect medication reconciliation to improve compliance? I have picked up literally thousands of major errors (incorrect drug, strength or frequency) working as an ED pharmacist in a public hospital where one of my primary roles in reconciliation. So in-line with the flawed logic of extrapolation used in this article we can go further to say that there is no evidence to support that choice of drug, dose or frequency has any impact on patient outcomes. 

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