Family Practice Vol. 16, No. 3, 278-282
© Oxford University Press 1999
‘Brown bag’ medication reviews as a means of optimizing patients' use of medication and of identifying potential clinical problems
a Department of Pharmacy, King's College London, Manresa Road, London SW3 6LX,
b Bexley and Greenwich Health Authority and
c School of Medicine, University of Leicester, Leicester, UK.
Alan Nathan.
Nathan A, Goodyer L, Lovejoy A and Rashid A. ‘Brown bag’ medication reviews as a means of optimizing patients' use of medication and of identifying potential clinical problems. Family Practice 1999; 16: 278–282.
Received 22 April 1998; Revised 18 September 1998; Accepted 28 January 1999.
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Abstract |
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Background. ‘Brown bag’ medication reviews carried out by community pharmacists collaborating with GPs have become established, in the USA and elsewhere, as an effective means of helping primary care patients to derive maximum benefit from their medicines, of identifying medication-related problems and of reducing wastage of medicines.
Objective. We aimed to determine whether ‘brown bag’ medication review could be used successfully in the UK, and particularly whether it represents an efficient and potentially cost-effective means of identifying medication problems.
Method. ‘Brown bag’ medication reviews were carried out on 205 volunteer patients in 23 pharmacies in south-east London. Pharmacists' interventions to improve patients' knowledge and usage of their medicines were analysed. Potential clinical problems identified by pharmacists were analysed in order to identify the drug groups most likely to cause problems.
Results. Interventions were made in 87% of reviews; interventions to improve patients' knowledge of the purpose and correct usage of their drugs were made in 65% of reviews. In 12% of reviews, problems were identified that could potentially result in a hospital admission, and the potential for an improved outcome for the patient if drug therapy was changed was identified in a further 34% of cases. Beta-blockers, NSAIDs and verapamil were identified as being associated with potential problems of the highest clinical significance. Patients taking psychoactive medication were at greatest risk of a medication-related problem from any cause.
Conclusion. Pharmacists could contribute to patients' welfare and reduce health care costs by carrying out ‘brown bag’ medication reviews on behalf of GPs.
Keywords. Drug therapy, elderly patients, family practice, patient compliance, pharmacist.
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Introduction |
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The need for patients on long-term medication to have it reviewed periodically is well recognized, but GPs often do not have the time to do this themselves and it has been recently suggested that nurses and pharmacists could be used to carry out medication reviews for GPs.1 In recent years, community pharmacists have been seeking ways to increase their involvement in their patients' clinical care and to become more closely involved in the primary health care team, and medication review would appear to be an area in which pharmacists' expertise could be effectively used.2
Medication review by pharmacists, using a method known as ‘brown bag’ review, was developed in 19823 and has become an established part of community health care in the USA, where it is now an integral component of managed care programmes.4 The method involves inviting patients to bring along for review by a pharmacist, either to the pharmacy or some other convenient setting such as a day centre, all of their medication that they have at home. In the original project, a brown supermarket bag was provided by pharmacists to patients to put their medicines into, hence the name which is now generally applied to this style of medication review. The brown bag concept has been taken up in other countries, including Denmark and Canada,5,6 and some small-scale projects have also been reported in the UK.7,8 A scheme has been reported in which prescribing problems were identified by nurses reviewing patients' medicines during home visits.9
This paper describes a pilot study carried out by community pharmacists in Bexley and Greenwich Health Authority in south-east London, to date the largest project of its kind carried out in the UK. Its aim was to determine whether brown bag medication review could be run successfully in the British primary care context. Within this, the main objectives were to determine whether, through brown bag reviews conducted by community pharmacists, patients might derive greater benefits from their medication, and whether the overall costs of patient care might be reduced.
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Method |
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All 48 pharmacies in four localities of the health authority were invited to participate, of which 23 accepted. Local ethics committee approval for the project was obtained. GPs in the relevant localities were informed about the project at local medical committee meetings.
The scheme was promoted locally through distribution of flyers to all households in the health authority localities in which participating pharmacies were located, and via posters in these pharmacies and local GP practices. Pharmacists were also trained to identify suitable patients who were known to them, and these were recruited in addition to those self-referred as a result of the advertising campaign.
A research associate pharmacist visited participating pharmacies, where the reviews were conducted, for half-day sessions and acted as locum while the resident pharmacist carried out medication reviews. The research associate was also available to provide advice to pharmacists, if required, and also monitored pharmacists' performance where possible. The locum services of the research associate pharmacist were provided free of charge, and pharmacists were in addition paid £6 per review, which was estimated to take about 30 minutes on average. Together these were equivalent to a payment of about £25 per hour.
Once recruited to the study, patients were issued with a brown bag and asked to bring to the pharmacy all their medicines from home. These included prescribed medications and over-the-counter (OTC) products bought for self-treatment, any medicines which were out of date or no longer used, and any reserve supplies. At the review, basic information about the patient was noted, and the medications were then reviewed systematically to identify contraindications, interactions, adverse reactions and problems with administration and compliance. Where necessary, the purpose of a medication was explained and advice given on dosage and/or administration, and compliance was encouraged. The information obtained was entered directly onto questionnaires set up on a notebook computer. Pharmacists were also encouraged, with patients' consent, to report to their GP any medication-related problems found or any significant intervention made. Pro-forma information letters were supplied for this purpose.
A system of grading the clinical significance of medication-related problems was developed by the research team and a grading was assigned to each review. Reviews considered to be clinically significant were submitted for validation to an expert panel consisting of a hospital consultant geriatrician, a GP with a specialist interest in clinical pharmacology, a hospital clinical pharmacist and a community pharmacist with advanced clinical pharmacy training. The grading system was modified in the light of their observations.
Statistical analysis was carried out using Minitab for Windows, Version 7. The Kruskal–Wallis test was used to compare the grading of clinical significance to the drug group primarily responsible for the problem identified. The chi-square test was used to identify patients taking certain groups of drugs who were likely to have a medication-related problem.
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Results |
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The scheme was open to any member of the public, but the rate of self-referral as a result of the publicity campaign was very low. This may have been because the concept of medication review was completely unknown to most patients, and some appeared suspicious that the scheme's objective was to check up that they were not wasting or hoarding medicines. Attempts were made to encourage GPs and their practice nurses to refer suitable patients for reviews, but were not very successful. In the event, more than 90% of volunteers were actively recruited by pharmacists, and consisted of mainly elderly and chronic sick patients on long-term medication.
Basic statistics
Medication reviews were conducted for 205 patients. Twenty-eight per cent of the patients were recorded as male (n = 57) and 54% female (n = 110); in 19% of reviews (n = 38), the gender of patients was not recorded or could not be deduced from patients' forenames. The mean age was 64.45 years (SD 17.55). The total number of medications reviewed was 1272, in 79 groups as classified by BNF code. The number of drugs reviewed per patient ranged from 1 to 14, with an average of 6.2.
Pharmacists' interventions
(a) In relation to medication reviews. .
Interventions were made in 178 (87%) of reviews. Pharmacists intervened to improve knowledge regarding the purpose of at least one of the medications that the patient was using in 133 (65%) reviews. Interventions to improve or correct usage of at least one medication were made in 46% of reviews. Fifty-eight per cent of patients either admitted to, or were suspected by the reviewing pharmacist of, either not using at least one of their medications at all or not using it/them according to prescribed directions. Pharmacists intervened to provide knowledge on common or important adverse drug reactions (ADRs) or side-effects (SEs) to 52% of patients for at least one of the medicines they were taking. Interactions between medications being used (some between prescribed and OTC medicines) were identified in 4% of reviews. Fourteen per cent of all medication reviews resulted in an information letter being sent to the patient's GP.
(b) In relation to individual drugs. .
Pharmacists' interventions in relation to individual drugs reviewed are summarized in Table 1
. In addition, incidence of ADRs or SEs was reported by patients for 19% of drugs reviewed, and patients knew about ADRs or SEs for 20% of drugs.
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Clinical significance of problems
Table 2
summarizes the grading of clinical significance of medication-related problems identified by the research team and assessed by the panel, and the number and percentage of problems at each level.
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In 20 (83%) of the cases identified as grade 1, the panel felt that, although the problem could potentially result in a hospital admission, further information would be required to confirm a true clinical risk. An example of a grade 1 intervention, confirmed by the panel, was that of a lady who had been told never to take NSAIDs following gastric bleeding after taking diclofenac, who had continued to buy and take aspirin for headaches unaware that it was an NSAID. A situation where the panel could not confirm a grade 1 risk without further clinical information involved an elderly patient taking verapamil, frusemide and captopril, who complained of tiredness and breathlessness. The reviewing pharmacist thought that the verapamil might be precipitating heart failure.
For interventions listed as grade 2, the panel felt that in 18 (26%) of the cases more information would be needed to ascertain potential benefits of a change in therapy. An example of a grade 2 intervention, confirmed by the panel, was that of an asthmatic patient taking aminophylline 400 mg who was complaining of nausea. The reviewing pharmacist thought that a check on theophylline levels might be advisable, followed by a reduction in dosage if appropriate. There were three cases identified of cough probably associated with ACE inhibitors, and two of hand tremor in patients taking oral salbutamol. In none of these cases had the patient made the GP aware of the problem.
The expert panel were not asked to comment on reviews graded 3 or 4.
Table 3 summarizes the relationship between the drug classes primarily identified as being associated with a problem during the review, based on the grading by the expert panel.
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There was a significant difference overall between the median score for the various drug groups (P = 0.003). From inspection of the average ranks, beta-blockers in particular were associated with potential problems of a higher significance rating as assessed by the review panel. All other groups were similar, although of these, problems with NSAIDs tended to be of ranked greater severity. Clinical problems resulting from issues of compliance were ranked as less serious, and were the principal cause of problems in 10 patients. Miscellaneous drugs were the main cause of problems in 12 patients. Further analysis of individual drugs and problems revealed that NSAIDs could have resulted in serious GIT problems in 14 patients, and verapamil was associated with problems with a high clinical significance rating.
An analysis was also made of the total numbers of patients taking the various classes of drugs who were identified as having potential problems, whether or not the problems were associated with that particular class of drug. Only those classes taken by at least 20 patients were analysed. On individual examination, psychoactive medication only was found to be significantly associated with a drug-related problem of any kind, with 75% of the 72 patients (P < 0.05) who were taking drugs from this group experiencing problems.
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Discussion |
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This study demonstrates that there are very few patients who are fully informed about their medicines and can use them without problems, and that there is therefore much scope for improving patients' knowledge and usage.
The project has also identified patients for whom special care needs to be exercised in prescribing generally. Thus, patients using psychoactive drugs appear to be at greater risk of drug-related problems of any kind (i.e. not just those related to their psychoactive medication) than other patients, and may need especially close monitoring. The problems were varied, but many of the patients concerned were elderly and taking benzodiazepine hypnotics. The well-documented problems associated with beta-blockers10 and NSAIDs11 in the elderly population have also been demonstrated in this study.
The study also showed that brown bag medication reviews can be useful in bringing to light problems which, for various reasons, may not readily come to the attention of the GP. Interactions between prescribed and OTC medications is one such area, as GPs are frequently unaware of what patients are buying for self-treatment of minor ailments.12,13 Potentially dangerous use of contraindicated OTC medicines is another.
Deliberate non-compliance is another area where GPs may be unaware of problems, as patients are often reluctant to admit to their doctor that they are not taking the medicines prescribed for them.14 This is illustrated by the case of a patient who was deliberately non-compliant with her oral hypoglycaemic therapy due to lack of understanding of her condition and to side-effects from the drugs. A number of reasons for poor adherence to prescribed medication were identified during reviews, including misinformation from friends and undue worry regarding adverse effects.
Evidence was also forthcoming from this study that medication review could be cost-effective in helping to prevent hospital admissions as the result of adverse drug reactions and poor compliance. About 12% of all reviews exposed the potential for hospital admissions as a result of ADRs or non-compliance. This is very much in line with levels found in other studies: ADRs have been estimated to be responsible for between 10 and 13% of all hospital admissions of elderly patients,15,16 and 5.5% of all elderly admissions have been attributed to non-compliance alone.17 The average cost of an elderly in-patient finished consultant event at Greenwich Hospital in the health authority area where the study was carried out was £3875 in 1996, so the potential savings are considerable. The potential for further cost savings, either directly on medicines and/or in reducing additional unscheduled visits to GPs, was identified in about 40% of all reviews in this project.
Patients appeared to appreciate medication review: follow-up interviews with a 10% sample indicated that, although beforehand some may have been wary of the process and suspicious as to its motives, afterwards they were unanimously in favour of it and thought that permanent schemes should be established.
One of the areas of the project in which difficulties were encountered was recruitment of patients. It became clear from follow-up interviews that patients would have been much more willing to participate if their doctor had recommended them to do so. Several pharmacists also suggested that closer collaboration with GPs was necessary for the success of this type of activity. They also thought that pharmacists should conduct the reviews in the GP's surgery, as it was a more suitable environment and there could be much better liaison with the doctor. The need for collaboration was underlined by the review panel's inability to confirm the seriousness of some of the problems identified without further clinical information about patients, which was not available to reviewing pharmacists.
Another aspect of the project that fell below initial expectations was the relatively low level of interchange of information between pharmacists and GPs. Several pharmacists were reluctant to send information letters when warranted because they were uncertain about how the doctor would receive them, fearing that they might be seen as an intrusion into the GP's area of clinical responsibility, an apprehension that has been previously reported.18 Feedback from GPs to pharmacists when information was sent was also very low, although some pharmacists reported that GPs sometimes appeared to have acted on it without communicating with them. GPs who had been sent information letters by pharmacists were asked for their opinions of the scheme; the response was very low (of the 17 GPs who were sent letters, only five responded to a short follow-up questionnaire), but those who did respond were generally in favour of it. If permanent medication review schemes are set up it is likely that health authorities or other sponsors will ensure that good interprofessional communication exists in order to get full value from them.
As with all exercises in which volunteers are recruited by open invitation, the sample was essentially self-selecting, and recruits, both patients and pharmacists, may have been individuals with a pre-existing positive bias. Another possible shortcoming of the methodology of the project was that in some cases the research associate was unable to monitor the performance of pharmacists while they conducted reviews. Where monitoring was not possible it was more difficult, using only the pharmacist's questionnaire record of the interview, to identify if any clinical problems had been overlooked.
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Conclusion |
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This pilot trial demonstrated that brown bag medication review conducted by community pharmacists is an efficient method of identifying medication-related problems, and could be operated on a general scale in the primary care environment of the UK. Brown bag reviews could help to identify and fill gaps in patients' knowledge about the purpose of their medicines and how to use them, thereby contributing to improved compliance and the benefits that patients derive from them. Through brown bag reviews community pharmacists could be valuable allies to GPs, helping them to maximize patient benefit and to reduce costs, both in terms of lower prescribing costs through reduced wastage and in time saved on additional consultations to resolve medication-related problems.
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References |
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