Background
The Community Pharmacy Medicines Management project was a large randomised, controlled trial evaluating the contribution of a community pharmacy-led medicines management service for patients with coronary heart disease (CHD). The service included a review of medicines by pharmacists. The aim of the study presented here was to describe the issues noted by pharmacists, and to identify any missed opportunities for recommendations.

Method
Community pharmacists’ documented issues and recommendations for all intervention patients which were then categorised by a practising clinical pharmacist/researcher (JK) and a practising general practitioner (GP)/researcher (AA) using a modification of a system developed previously¹. An in-depth analysis was conducted for a subset of patients to explore the potential for pharmacists to identify issues. This sample comprised up to three patients per pharmacist with consultations being sampled at different time-points throughout the study i.e. one patient early in the study, one around the mid-point and one at the end.

For the in-depth analysis, the reviewers independently assessed the clinical record noting issues and classifying them¹. Where complete agreement between the two researchers was not reached initially, consensus was reached by discussion.

Results
From the analysis of all patients seen, the median number of issues and recommendations noted by pharmacists was three. A total of 2228 issues was noted, the most frequent being the need for monitoring (27%) or treatment (15%), potentially ineffective therapy (10%), and lifestyle issues for CHD (10%). Of 2337 recommendations made, the most frequent were for monitoring (32%), adding a drug (12%) and lifestyle advice (11%).

With the in-depth review of the subset of 169 cases the clinical pharmacist, GP and study pharmacists noted 1328, 1732, and 582 issues, respectively. Of the issues noted by community pharmacists, 158 were not identified by either reviewer. The total number of issues identified by either reviewer or by a study pharmacist was 1961. There was initial agreement between reviewers on the presence and classification of 910 of the 1961 issues (46%). Following discussion, 1539 (78%) of these 1961 issues and 146 (92%) of the 158 issues noted only by study pharmacists were agreed as appropriate for further analysis, generating a total of 1685 identifiable issues. Community pharmacists identified 570 (34%) of these issues. For the three categories that were the main focus of the intervention, ‘need for additional therapy’, ‘potentially ineffective therapy’, and ‘lifestyle issues’, 42% of possible issues were documented by study pharmacists.

Discussion
This method of describing and measuring the completeness of pharmacists’ medication reviews may be useful for evaluating the outcomes of medicines management training. However, it is possible that the results may underestimate the completeness of reviews due to the failure of community pharmacists to fully document the issues or recommendations they identified.

References

1. Krska J, Hansford D, Jamieson D, Arris F, Cromarty JA, Abbott S, McGuire A. A classification system for issues identified in pharmaceutical care practice. Int J Pharm Pract 2002; 10: 91-100