Discussion
Based on a literature search and review, and on questions to our
international network, we believe this is the first prospective and
controlled study to evaluate a community pharmacy based CDSS on
pharmacists’ identification and resolution of DRPs. Our study is small,
but it indicates that the EES-support system contributes to
identification of actual drug related problems (DRPs). The number of
patients with at least one DRP did not increase but the number of
patients with at least 1, 2 and 3-5 DRPs did. This is what should be
expected for a support system. EES gives a total review of all
prescriptions. This helped the pharmacist to suggest initiatives towards
physicians, but not toward patients to resolve DRPs. The help mainly
concerned drug-drug interactions. This seems to be the major
contribution of EES, to assist pharmacists in suggesting the removal or
switch of a drug, or decrease the dose due to drug-drug interactions. In
fact, if the drug-drug interaction DRPs are removed (table 4) there is
no apparent difference between the groups.
There have been few publications on systematic documentation and
resolution of DRP in community pharmacies.7-11 In a
German study from 2005, DRPs were examined at 1,114
pharmacies.7 The pharmacists documented approximately
10,500 DRPs, and more than 80 percent of the DRPs could be resolved, in
large part in consultation with the prescriber. In another German study,
141 pharmacists documented 912 medication reviews during
2012-2015.11 In 869 of these (95%), the pharmacist
documented at least one DRP. In total they found 5248 DRPs. In 3972 of
these (76%), an action to solve the problem was documented and in 3198
(61%) it was rated as resolved. In a Dutch study from 2012, data was
collected from 268 community pharmacies.8 In total,
4579 medication reviews were performed and 13,366 DRPs were found, on
average 2.9 per patient, of which 0.90 led to medication changes. A
French study from 2014 included 892 patients from 55 pharmacies. 334
DRPs were identified, 259 actions were reported and 89 were sent to the
physician who implemented 70 of these.10
All studies were performed on populations similar to ours, with limited
access to health-care patient data, but in several community pharmacies:
They used standardized documentation templates but the method or support
system (CDSS) for identification of DRPs was not described. We have
found only one community pharmacy study using a CDSS and reporting DRP
signals similar to our study.11 This is a Dutch study
from 2014 where they took a random sample of 10% from a CDSS database
from 123 pharmacies, generating 1,672,169 dispensed prescriptions from
81,742 patients. Of the dispensed prescriptions 43% led to one or more
safety alerts, 31-55% range over pharmacies. They reported that the
majority of the alerts were clustered in a minority of patients and
involved mainly drug-drug interaction (15%), disease-drug interactions
(14%), duplicate medications (13%) and dosing alerts (7%). They did
not report actions or resolution rates.
We were very surprised by the low number of identified DRPs in our
study, compared to other studies 7-11 and our power
calculation was consequently not fully appropriate. The definition of a
DRP is part of the discrepancy. It seems as most of DRPs in the
described studies are potential. In our study only actual DRPs were
documented. Our study pharmacy has for many years had a close
collaboration with the local GPs and also a continuity among the
patients coming to the pharmacy. It could be that the patients in fact
are very well treated, having a low number of DRPs.
Two studies have previously been published in the EES-support system
based on nursing home patients with multi-dose drug
dispensing.13-14 In order to get an idea of the
clinical significance of EES signals, physicians’ views on the signals
were assessed.13 Sixty-eight percent (502/740) were
considered clinically relevant and in 276 of these had the physician
intended to take action. For 135 of these 276, the measures were to
either insert or withdraw drugs, or reduce or increase the dose.
Following up, it was shown that 85 of these 135 had led to an actual
change in the prescription. In another study EES alerted in 76 percent
of patients.14 The most common alerts were drug-drug
interactions, drug duplications and inappropriate drugs or high doses in
older patients. The basics in these studies are similar to ours but but
the higher number of DRPs could be explained because they also
documented potential DRPs.
There
are some limitations in our study. The participating pharmacists were
aware of the study and the EES support period. However the number of
patients with at least 1 DRP was in fact lower in the EES-group which
indicates a low risk of attention bias. Due to a single center study
design involving only three pharmacists with different experiences the
generalizability could be low. However, since the use of EES is very
standardized, the different experiences among our pharmacists might
increase the generalizability.
Previous studies13-14 have shown the clinical
significance of the system and pharmacist suggestions. This study adds
information that EES-support increases the identification, suggestions
and resolving of DRPs. Future studies should focus more on clinical
effects of EES-support, and cost-effectiveness. A major problem is also
to involve the pharmacies/pharmacists in the establishment of a correct
medication list of what medicines the patients actually take. We have
previously studied this as part of the Lund Integrated Medicines
Management model and found major problems in the correctness of
medication lists when patients are admitted and discharged from
hospital.17 Cancelation of not used prescriptions is
possible by pharmacists and could be an active and integrated part to
help patients and health-care professionals to establish a correct
medication list, which needs to be studied.