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.