Clinical interventions in Australian community pharmacies

Introduction Drug related problems (DRPs) are a common cause of morbidity and mortality. The resolution of DRPs, once they are identified, has the potential to reduce healthcare costs and improve outcomes for individuals taking medications. The role of community pharmacists in the identification and resolution of DRPs (that is clinical interventions or Cls), and the value of such interventions has not been adequately studied in Australia. Aims The aims of this project were to, in relation to community pharmacies in Australia: ‚Äö evaluate the types of DRPs and the drugs involved, ‚Äö determine the frequency with which pharmacists resolve or prevent DRPs, and ‚Äö estimate the potential value of pharmacists' Cls in health and economic terms. Methods A classification system for DRPs and the way the problems could be resolved was developed and integrated into pharmacy dispensing software. A secure messaging system was developed that allowed details of the Cl and other relevant information to be transferred to an electronic repository. Survey instruments, documentation techniques and communications were pilot tested in Tasmania. Modifications were made and a study using the modified communication and documentation software was conducted in 52 pharmacies in Melbourne, Victoria over eight weeks. Pharmacies were randomised to receive remuneration and an intervention prompt integrated into the dispensing system. Some pharmacies were allocated observers to assist in the documentation process. A sample of 291 of the Cls was assessed by a panel of 16 experts using a web-based interface. Experts estimated the probability of particular consequences occurring before and after the Cl, enabling an estimate to be made of the value in terms of potential costs avoided, hospital and medical consultations avoided and days of adverse health avoided. Results Over the eight week study, 435520 prescriptions for 258979 patients were dispensed and information concerning 2385 CIs was documented (a frequency of 0.55 CIs per 100 prescriptions and 0. 92 CIs per 100 patients). The presence of an observer increased the frequency of CIs recorded more than two fold. Remuneration did not provide any additional effect in observed pharmacies, but remuneration had a short term effect on Cl frequency in pharmacies that did not have an observer present. The intervention prompt was effective in prompting 201 specific CIs in the pharmacies where it was installed. The prompt also increased the overall Cl frequency almost two fold in pharmacies where the prompt was installed. The majority of CIs were one of three categories: drug selection problems (22.7%), dosage problems (19.4%) or education or information problems ( 17.4%). Drug groups commonly associated with clinical interventions were antibiotics, drugs for diabetes, cardiovascular drugs and drugs for respiratory disorders. Almost one third of the clinical interventions were classified as either of moderate or severe level of clinical significance by the recording pharmacist. In almost 90% of cases, the pharmacist investigated the drug-related problem by discussing the issue with the patient or the carer. In one third of cases, the pharmacist contacted the prescriber in order to clarify the problem. Recommendations for changes in therapy were made in 67%, and information or education was provided in over 50% of CIs. The clinical and economic analysis suggested that the value of Australian community pharmacist interventions related to prescription medication is in the order of $200M each year in direct costs avoided. In addition, around 170,000 hospital bed-days are avoided and 25M days of adverse health impact are avoided each year. As a result of each Cl by a pharmacist, there is a mean reduction of: ‚Äö 34 days in a lowered health status (3. 7 days of severe poor health, 16.6 days of moderate poor health and 13.4 days of mild poor health), ‚Äö 0.13 days in hospital at a cost of $100 ‚Äö 0. 7 GP consultations and 0.14 specialist consultations at a cost of $23 to Medicare Benefits Schedule (MBS), ‚Äö further investigations at a cost of $25 to MBS, ‚Äö a total of $150 in total direct costs (MBS and hospital combined). Conclusions The PROMISe project and the associated pilot study have together provided the most comprehensive information currently available concerning clinical interventions undertaken in Australian community pharmacies. Community pharmacists undertake approximately one Cl every 200 prescriptions. These Cls usually involve a drug selection, dosage or education problem associated with antibiotics, drugs for diabetes or cardiovascular drugs. The estimated average value of each Cl was $150 in direct costs, which extrapolates to approximately $0.5M daily across Australia.