4 Discussion
To the best of our knowledge, this study was the first to evaluate the outcomes of pharmacist-led MTM services in ambulatory elderly patients in mainland China. This study showed that the proportion of patients with DRPs was high, with an average 2.15 per patient. Interventions by pharmacists significantly reduced the cost of medication and improved clinical outcomes (BP and lipids level). The average cost of medications per patient for every month decreased from 387.72 to 355.17 RMB in our study. It suggests that the pharmacist-led MTM services played an important role in improving health outcomes and saving medication cost.
To be able to perform MTM services with high quality, the pharmacists need to have full access to patient’s medical and laboratory records. Compared with many other outpatient clinics, in order to obtain more comprehensive information, the pharmacists collected the medical records of each patient for 30-40 minutes, including previous medical history, previous medications, current medications, laboratory examination and other information. This was important, for example, to understand why a drug had been changed or to identify any adverse effect of earlier drugs.
In previous studies, the average number of DRPs per person was lower than the result in our study [16, 17]. A study from Australia reported that 130 DRPs were found in 73 patients (mean 1.8 DRPs per patient) [16]. Rhalimi et al revealed an average of 1.37 DRPs per patient in French community pharmacies [17]. There might be several explanations for why the number of DRPs in this study was higher than in other studies. First, our study was conducted in a tertiary hospital rather than a community pharmacy. Most of the patients who come to the pharmacist clinic had medication problems, so there were more DRPs than other studies. Second, there were several available tools to evaluate DRPs. We chose to use the PCNE V8.03 classification system, but other available assessment tools may differ slightly in some aspects, and therefore, other tools may observe different results.
Adverse drug event (possibly) occurring was quite common problems of DRPs in our study. This was also the most common pharmaceutical care problem in the Kwint’s study [18]. This finding could give support to the hypothesis that pharmacists have adequately addressed patients’ problems in the pharmacist outpatient services. For example, it was well known that elderly people were at high risk of side effects from non-steroidal anti-inflammatory drugs (NSAIDs), such as gastrointestinal bleeding and renal toxicity, and that NSAIDs also increase the risk of hypertension and heart failure [19, 20]. High doses of dihydropyridines calcium-channel blockers often caused ankle edema, headache, flushing and tachycardia [21]. In order to reduce the occurrence of adverse reactions, the pharmacists may reduce the dose of the drug or switch it to another medicine according to the symptoms.
In our study, no or incomplete drug treatment in spite of existing indication was the main causes subtype of DRPs. For example, some patients did not receive the standard ”ABCDE” method for secondary prevention of coronary artery disease: antiplatelet therapy, blood pressure management, cholesterol management, diabetes treatment, and exercise; it was recommended that it was often used to reduce the cardiovascular risk [22]. Although cardiac rehabilitation following a cardiovascular event is a Class I recommendation of the European Society of Cardiology, the American Heart Association and the American College of Cardiology, it remains vastly underutilized, accounting for 15% to 50% of the targeted population participating in such services [23-27]. Lack of awareness on the importance of those drugs and fear of ADRs were possible causes. The high incidence of incomplete drug treatment in our study highlights the need for pharmacists to conduct a MTM services in elderly patients to optimize drug treatment.
The overall acceptance rate of pharmacist interventions was relatively high (90.48%), which was higher than what has been reported in other studies [28, 29]. This is probably due to the fact that adequate training and experience in clinical pharmacy are important factors for meeting the specific challenges of MTM service.
Multivariate analysis showed that the number of drugs taken was associated independent risk factor for the number of DRPs, which was consistent with most previous studies [30-32]. Patients taking large amounts drugs tend to experience adverse drug reactions, potential drug–drug interactions, decreased compliance and drug selection problems [33-35]. It was recommended that patients could visit pharmacist clinic to conduct medication reorganization and reduce unnecessary drugs. Pharmacists can review medication history and identify medication issues in these patients. Pharmacists were familiar with not only medication but also the interaction between the drug and the disease. Therefore, it was recommended that pharmacists could provide MTM services for ambulatory patients who receiving long-term pharmacotherapy [36].
After one year MTM service, the improvements in several clinical outcomes among the patients were significant. Hypertension and hyperlipidemia increase the risk of fatal or non-fatal cardiovascular events [24-26]. Like other studies, our study also found that the MTM service improved BP and lipid level among patients [37-39]. Regarding cost-saving effect, the post-intervention group experienced a significant reduction in total costs of medications per patient for every month. This decrease in medication expenditures was similar to those reported in other MTM services studies [37, 40].
Some limitations of this study have to be taken into account. First, it was a retrospective study and the patient population in this study was small. This could lead to non-significant results. Second, all involved pharmacists performed comprehensive medication reviews as described in the methods section. Still, limitations in the inter-rater reliability cannot be ruled out. Finally, the lack of usual care group was a limitation of the present study, therefore, in terms of clinical outcomes and cost-saving effect, the self-comparison study of patients pre- and post- intervention were conducted.