An evaluation by patients of pharmacist-led medicines management in southern England

Introduction

The Woodlands elderly resource team is a multidisciplinary intermediate care and rehabilitation team based in Poole, Dorset. This study set out to evaluate the service provided by the medicines management section of the team using patient interviews.

The medicines management team (MMT) consists of pharmacists and pharmacy technicians who visit and provide pharmaceutical care to patients in their homes. The key aims of the service are to prevent hospital admission, provide independence for patients when taking medicines and to improve patients’ experiences of pharmaceutical care. Patients are referred to the MMT by health and social care professionals. Occasionally referrals are received from patients’ families or friends, but these referrals are redirected via the patient’s GP.

The assessment process covers both clinical appropriateness and issues around compliance with drug regimens. Interventions include patient education, regimen simplification, dose titration, pain management and provision of a range of compliance aids to help patients take their medicines.

The team communicates with other healthcare professionals involved in a patient’s care to optimise outcomes. Communication is via the normal referral channels for the particular service needed by a patient, for example, a Parkinson’s nurse specialist, palliative care nurse specialist, sight and hearing loss team and social services care managers.

Data reported in the pharmacy White Paper of April 2008 suggest a reduction in hospital admissions for patients who have had pharmaceutical care provided by MMTs.^[1]
 Anecdotal evidence from members of the MMT suggests a link between patient satisfaction with the service and good relations between the patient and the pharmacist. This would further strengthen the motivation to cooperate with suggestions from the pharmacist. This complies with one of the goals of the NHS plan^[2]
 published in 2000, which outlined the need for patients’ views on services to inform service development.

This study is not designed to support or refute any other published work. The authors suggest it may be the first study to elicit patients’ views about a domiciliary service since a literature search did not find any similar studies.

Methods

The researcher was a final-year pharmacy undergraduate who did work experience with the Woodlands MMT. The researcher was not known to any of the patients enrolled in the study and had no role in providing MMT services to any of the participants.

Patients’ eligibility for the study was limited to those who had been managed by the Woodlands MMT for at least the previous 28 days. Patients who had been discharged to the continuing care of a community pharmacy were excluded, as were patients for whom agency carers were employed to organise medication. Patients who were helped with their medicines by a carer such as a family member, were not excluded provided they still had involvement with their own medicines. Patients with severe cognitive loss were excluded, as were those presenting a potential risk to the researcher as indicated by an MMT risk assessment.

The data collection period was July 2007 to February 2008. Of the 130 MMT patients who could potentially have participated in the study, 67 satisfied the inclusion criteria.Five of those refused to take part on the grounds that they could not spare the time, and seven could not take part as a result of their admission to a hospital or care home during the data collection period. The proportion of men to women who were excluded was similar to that of the study population (34.6 per cent of men in the excluded population versus 40 per cent in the study population). The mean age of excluded patients was 82.1 years, slightly higher than the study population.

The study population consisted of 55 subjects (60 per cent female), with a mean age of 79.8 years (range 35–97 years). Thirty-eight subjects had been managed by the MMT for 29 to 168 days at the date of interview and 17 subjects for longer (169 to 921 days). The mean number of regular long-term medicines taken by the study population was eight (range 2–18; mode 8), the mean number of chronic diseases diagnosed in the study population was three (range 0–9; mode 3).

For 29 per cent of subjects another person was present during the interview. In all cases this was a family member who was present as an observer with the permission of the interviewee. The type of intervention made by the MMT was recorded; 50 of the 55 patients had their medicines repackaged into a multi-compartment aid (MCA) and three patients were using alarmed rotating electronic medicines dispensers. The remaining two patients had realignment of medicines. This was done to ensure that prescribed quantities were adjusted so that reordering of all medicines was carried out at the same time each month.

The researcher designed the questionnaire (available from the author by request), included concepts in it that were developed through observation, information gathered about the MMT service, consultation with its lead pharmacist and a review of literature and texts.^[3],[4]
 The questionnaire was assessed in a pilot study for content validity (whether it is a sensible measure for the investigation being undertaken), ease of use, acceptability and ability to be understood. Minor adjustments were made following patient feedback.

Eligible patients were contacted by telephone. The study was explained to them and they were invited to take part. If they agreed to participate an appointment was made for the researcher to visit them at home to conduct the interview.

A questionnaire was completed by the researcher during a direct structured interview, where all subjects were asked the same questions. This method was chosen to ensure the largest possible response rate and to obtain quantitative data for analysis. It was decided to offer a standardised explanation to any questions not fully understood by the respondent, to minimise interviewer bias. For example, the standard explanation given to define a problem in the question “Did you have problems taking your medicines before the medicines team visited you?” was “Were there any obstacles to ordering and obtaining medicines, extracting them from packaging or swallowing?”. In a predominantly elderly population the direct structured interview enabled those with impairments such as poor sight or poor manual dexterity to participate.

The questionnaire consisted of three questions to which the respondent could reply “yes”, “no” or “don’t know”. Fifteen questions used a five-point Likert scale. All had a nil response option. Since all the participants in the study had some degree of cognitive impairment, we decided to exclude negatively phrased statements because they require a level of mental agility for which the patients had not been assessed. If patients had experienced difficulty in understanding the statements this might have confounded the results.

For each set of questions the patient was presented with large-print laminated cards explaining the type of response required. Each question was read to the patient by the researcher, who recorded the response. Any comments volunteered by the patient during the interview were recorded by hand on the questionnaire. Interviews ranged from 20 minutes to one hour.

Any information relevant to the study and not obtainable from the patient was obtained from the MMT notes. Diagnosis of chronic disease was accessed from clinical coding notes in the patient’s medical records.

The study was defined as a service evaluation (NRES, 2006), therefore ethics committee approval was not needed. However principles of informed consent and good ethical research practice were adopted. Permission was granted by Bournemouth and Poole Primary Care Trust to conduct the evaluation.

Results

Fifty-three subjects had at least one diagnosed chronic disease, with a large proportion diagnosed with three chronic diseases. The two subjects recorded as having no diagnosis of chronic disease required palliative care management. Six subjects in total required palliative care and 16 subjects were receiving anticoagulant therapy, which required close monitoring. Most chronic diseases recorded were disorders of the cardiovascular system.

Although all interviewed subjects had been involved with the MMT service for at least 28 days and had received some assistance with their medicines, 73 per cent believed that they did not have any problems taking their medicines before the MMT visited them. These patients were referred by health or social care professionals who believed that they were taking too much or too little medicine.

Upon review, the medicines management team confirmed that although patients were originally unaware of the problem, their referrers were usually correct in thinking there were problems. It was more common for patients to take too little medicine than too much. Patients who frequently took too little medicine continued to order repeat medication regularly, which disguised their non-compliance until a home visit was undertaken.

Reasons for failing to take medicines correctly included forgetting to take it, difficulty getting tablets out of packets, swallowing difficulties, sight impairment, confusion when the appearance of tablets changed and not knowing which medicines had or had not been taken.

Only 40 per cent of patients reported that the MMT had arranged for changes to their medicines. This was most clearly demonstrated in those requiring anticoagulation management, since they were aware of regular changes made in line with their INR result. Of the 15 per cent of patients who were not aware of any changes to their medicines some did not feel the need to know. Of the 84 per cent who said that changes had been made to the way that they take their medicines this was mainly in relation to their medicines being repackaged into an MCA or electronic dispenser.

Fifty-eight per cent of patients either strongly agreed or agreed that the team involved them in any changes made to their medicines, 14 per cent disagreed and the remainder were undecided or did not respond. A nil response was recorded if the subject was unable to recall any specific changes made.

Patients were then asked the extent to which they agreed with the statement “I understand the changes made to my medicines”. Forty-seven per cent strongly agreed or agreed with the statement. This was the only question with which some patients disagreed (two patients, or 4 per cent). It emerged that some patients did not wish to understand the changes made to their medicines. One commented: “I just accept what medicines I am given, I trust the medicines team, my GP and also the warfarin clinic.”In fact 83 per cent of subjects strongly agreed or agreed with the statement “I accept the changes made to my medicines”.

Within the 89 per cent of patients strongly agreeing or agreeing that “the changes made to my medicines help me to take them correctly”, many positive remarks were made about the repackaging of medicines into an MCA. Four patients disagreed with the statement, one of whom commented: “I have found no difference.” Two others found the new system (provided by the MMT) either much easier or more convenient.

Asked whether “the medicines team service contributes to my level of independence” 65 per cent of respondents strongly agreed or agreed with the statement. For some patients the service had a profound effect in that they thought they would be able to manage in their own homes for longer; others saw that it assisted if they lived alone or were house-bound. Some thought that the question was not relevant in that they could not see how the medicines management service would affect their independence.

Although most of the sample (60 per cent) strongly agreed or agreed that “I have a better understanding of my medicines since being visited by the medicines team”, 33 per cent disagreed. Some of those who disagreed said that this was because they already had a good understanding of their medicines and the team did not contribute to what they knew. The patient’s perception about level of understanding was accepted without challenge. Ninety-eight per cent of patients strongly agreed or agreed with the statement “I feel comfortable discussing my medicines with the medicines team”.

When asked whether the medicines team were able to answer any questions about their medicines, 67 per cent strongly agreed (27 per cent did not give an answer). When asked whether the information provided by the medicines team was useful, 62 per cent either agreed or strongly agreed (31 per cent did not give an answer).

Eighty-five per cent of patients strongly agreed or agreed with the statement “I understand the need for the medicines team to discuss my medicines with my GP”. Two patients disagreed with this statement with one commenting: “It’s up to the doctor to make changes to my medicines.” Ninety-one per cent accepted the need for the team to discuss their medicines with their GP.

Some 94 per cent of subjects strongly agreed or agreed that “the medicines team members are friendly”, and 83 per cent of patients strongly agreed or agreed that “the medicines team members respected my dignity”. All the other patients failed to respond. In some cases patients believed that the service did not involve the issue of dignity since it was not an intrusive service compared with, say, the removal of clothing. One Parkinson’s disease patient commented: “I no longer have any dignity to respect.”

Ninety-six per cent of patients strongly agreed or agreed that “the medicines team member behaved in a professional manner”. Seventy-eight per cent of patients were very satisfied and 22 per cent were satisfied “with the overall service provided by the medicines team”.

Forty-eight of the 55 subjects volunteered comments during the interviews. Themes that emerged included the effect of interventions and changes made by the MMT, communication between the MMT, the GP and patient, problems encountered with their medicines and how the service affected their independence. Volunteered comments are discussed below.

Discussion

All subjects interviewed were at least satisfied with the service provided by the MMT and responses indicate that patients perceived one or more benefits from the service.

A high proportion of respondents thought that they had no problems taking their medicines before being visited by the MMT. The response to this question largely depended upon interpretation of what the patient defined as a problem. Most respondents associated problems with the physical act of taking medicines — those who had swallowing difficulties, for example, would have identified this as a problem.

This question was perhaps too broad and could have been broken down into further descriptive questions, investigating the problems encountered at the different points of ordering, obtaining, understanding and taking medicines.

There were those also who would not admit to encountering problems with their medicines; however, they all agreed to receive assistance from the team. At all stages of the process the patients’ autonomy was respected and they had the opportunity to withdraw or refuse any further input by the MMT. All patients had been originally referred to the service because another health or social care professional had identified one or more problems with medicines.

Changes made by the medicines management team might include the stopping or starting of a treatment in agreement with the prescriber, reducing the number of dosing periods in a day or repackaging regular long-term medicines in a more user-friendly way. Such changes were discussed and made in agreement with the patient.

Twenty-nine subjects did not agree that they understood the changes made, however 21 did accept the changes; one patient strongly disagreed that she understood the changes made yet strongly agreed that she accepted them. It seems that most of the population trusted interventions made by the MMT even in the absence of understanding. It is difficult in the context of the literature on concordance to assess whether or not this might lead to a high level of adherence in this group.

Most patients in the study had their medicines repackaged into MCAs. Other patients with only a brief intervention, such as provision of reminder charts, large print labels, dexterity aids or simplification of dosage regimens, were discharged fairly quickly from the service. These patients were under-represented in the study group.

A large proportion of patients attributed being able to take their medicines correctly to having their medicines repackaged into a MCA. Many comments were volunteered about the use of blister packs. This intervention seemed to have a positive impact. Problems resolved using this system included ease of use where problems had occurred getting tablets out of original packs due to lack of manual dexterity or sight problems. For many patients, receiving their medicines in original packs caused an assortment of difficulties, including keeping track of what medicines had or had not been taken. This is described here by one patient:

The blister packs are very good — I never knew if I had taken too many or not enough when the tablets were in separate [original] packs. It was always confusing having all my tablets in different packs — I have nine tablets to take in the morning, I would line them all up and sometimes I might take 10 or sometimes only seven or eight because I couldn’t remember what I had taken.

One subject had found multiple packs demotivating:

Having all the tablets in different packs made it a chore to take them and if I felt well I wouldn’t take them, I had a stroke and I think it may have been because I didn’t take my tablets. Now they are in the blister packs it is much easier and I make sure I take them twice a day — my diabetes and blood pressure are very well controlled.

Sorensen in 2000 outlined “lack of medication administration routine, therapeutic duplication and poor adherence” as factors related to poor health outcomes.^[5]
 It is possible that subjects may have better health outcomes from MMT interventions that address the issues mentioned, but evidence of this is beyond the current research.

All but one patient felt comfortable discussing their medicines with the MMT. Most also found the team friendly, respectful of their dignity and professional; this would aid the pharmacist–patient relationship supporting a potentially high level of adherence to therapy among the study population.

It was encouraging that most understood and accepted the need for the medicines management team to discuss their medicines with their GP. One patient asserted:

It is vital for the medicines team to discuss my medicines with my GP.

This supports Bajramovic’s research, where consumers felt the need for harmonious relationships between health professionals.^[6]
One subject thought that this relationship was not apparent:

There seems to be a lack of cohesion between healthcare professionals and also between them and patients.

In Bajramovic’s study consumers wished for more participation from health professionals and to be given more information about treatments. Of the MMT study population, those who recalled asking questions about their medicines found the information provided useful and some suggested that the discussion and information provided by the team was more than they might get from their GP. One patient also commented:

Pharmacists are more knowledgeable about medicines than doctors — far more specialised

This comment provides support for Nathan’s research in relation to the enhanced perception of pharmacists by patients.^[7]

Another was reassured that:

My health is being watched over with regards to my medicines.

It was also suggested that the personal interaction with the team motivated patients to take their medicine:

The one-to-one situation gives the patient incentive to take their medicines.

A key aim of the medicines management service is to provide independence for the patient when medicating; as discussed earlier most believed that the service contributed to their level of independence but some were unsure how the service impacted in this respect. Subjects’ definitions of independence varied. To some the service assisted their independence if they were housebound or lived alone since it enabled them to obtain their medicines. Others felt that with the input of the team they were able to remain in their own home for longer as tools were provided to enable them to manage their own medicines independently.

Two subjects commented that the service takes the responsibility for medicating away from the patient:

Since coming out of hospital my memory has not been so good and I didn’t know where I was with medicines, Woodlands takes the responsibility and worry from me.

Another patient said:

The concept [MCA] is brilliant. It takes the responsibility away from somebody who is unwell and not able to make reasonable decisions about their medicines.

This loss of responsibility for a patient’s own medication is identified as a disadvantage by Nunney and Raynor in the use of MCAs.^[8]
 However, despite reducing their responsibility for their own medication, it was reported by patients in this study that the use of MCAs made a positive contribution to their independence.

There was no indication that any advice given by the MMT was rejected or resisted or that the subjects felt undermined in any way, as suggested by Salter et al. Their 2007 study found that advice given to patients by a pharmacist during medication review “was often resisted or rejected”, concluding that “the advice-giving role of pharmacists during consultations with patients … has the potential to undermine and threaten the patients’ assumed competence, integrity, and self-governance”.^[9]

The Salter study was carried out in a different context to this study, which could account for the apparent difference in response. In Salter, the medicines review was not related to a particular service, whereas this study was undertaken on behalf of a service the patient would have been familiar with. In the case of this study all subjects were in the service by agreement, it might be appropriate to investigate any patients who had been visited by an MMT pharmacist but who had chosen not to participate in the service.

Limitations of this study include the lack of generalisability to other populations because the MMT service is not based upon a standard pharmaceutical care model. The small sample restricted the statistical validity of any tests performed upon the data; increasing the period for data collection would have increased the study population.

There may have been a degree of bias: all subjects at the time of interview were being supported by the MMT. There may have been an element of social desirability in responses leading to an inclination to answer positively if it was thought that the service provided by the MMT might be jeopardised if subjects responded in negatively. However, only five patients declined to take part in the survey, minimising self-selection bias.

In 29 per cent of interviews a relative of the subject was present; any input from this person may have influenced responses from the patient. In some cases useful feedback was received since the service had had an impact on that person, for example, a spouse who jointly managed the subject’s medication before input by the MMT. In these cases it might have been appropriate to have an independent evaluation of those involved in the care of patients of the MMT.

The evaluation suggests that the MMT satisfies its key aims to provide independence for patients when taking medicines and to improve the patient experience of pharmaceutical care. The evaluation identified a good level of communication and information sharing between patients and the MMT thought to be valuable in optimal pharmaceutical care. This, at least partly, fulfils the Department of Health milestone in the National Service Framework for Older People: “By 2004: Every primary care group or primary care trust will have schemes in place so that older people get more help from pharmacists in using their medicines.”^[10]

Further research in this area might assess the effect MMT interventions have on adherence to treatment. If a high level of adherence is achieved this may lead to better health outcomes, supporting data that indicate a reduction in hospital admissions for patients who have had pharmaceutical care provided by the MMT.