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| Journal of the New Zealand Medical Association,
24-April-2009, Vol 122 No 1293
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Examining the first year of Medicines Use Review
services provided by pharmacists in New Zealand: 2008
Evan Lee, Rhiannon Braund, June Tordoff
Many people take several medicines a day to help control
chronic medical conditions. Nevertheless, estimates suggest that only about 50%
of such people adhere to treatment
recommendations.1 Thus some people may not
benefit fully from their medicines, and many “health dollars” may be
wasted. “Adherence support” medication reviews (ASMRs) by
pharmacists are one type of intervention shown to improve adherence to
therapy.2–4
Governments in some countries are funding community
pharmacists to provide such reviews in collaboration with patients and GPs in
order to improve patients’ use of medicines (e.g. Medicines Use Reviews
[MURs] in the UK).5–7 Patients and
providers appear satisfied with such services and a recent UK study indicated
that GPs implemented (on average) 56% of pharmacists’ recommendations
resulting from such reviews (MURs).8
ASMR is one of several types of medication review undertaken
by doctors, pharmacists, or nurses and has been categorised as a level 1 review
according to a UK organisation, the National Collaborative Medicines Management
Service Programme (NCMMSP).9,10
The categories are:
Clinical medication reviews (level 3) have
been shown to be effective in regard to: optimising therapeutic outcomes,
reducing the number of drug-related problems and reducing pharmaceutical
waste.2,11,12 The NCMMSP define a medication
review as “a structured, critical examination of a patient’s
medicines with the objective of reaching an agreement with the patient about
treatment, optimising the impact of medicines, minimising the number of
medication-related problems and reducing waste.”
9
Pharmacists in New Zealand have worked collaboratively with
GPs for almost two decades providing medication reviews for selected patients.
The first generation of reviews, Pharmaceutical Review Services (PRS), was
introduced in 1998. These involved pharmacists reviewing patient’s
medication collaboratively with the patient and GP, and were clinical medication
reviews (level 3) with access to clinical notes.13
A maximum of one review per patient enrolled per year was funded by the
government. PRS ended in 2004 following health service reorganisation and the
devolvement of budgets to district health boards (DHBs).
In 1996, a second generation of medication reviews,
Comprehensive Pharmaceutical Care (CPC®),
was introduced.13 This adopted a model from the
USA that involved a pharmacist working in collaboration with the patient and GP
in order to identify and resolve actual and potential drug-related
problems. Again these were clinical medication
reviews. Unlike PRS,
CPC® is still underway in New Zealand.
Nevertheless this is not a government funded service, and the patient must bear
the cost themselves.
In 2007, as part of the National Pharmacist Services
Framework, Medicines Use Review and Adherence Support services (MURs) were
introduced in New Zealand.14 MURs, a level 1
type of review, aim to provide “adherence support” for selected
patients. MUR is a pharmacist-led, structured, systematic, consultation-based
review of a patient’s medication.14 It
involves reviewing a patient’s medications, identifying any practical or
medication-related problems, and educating the patient about their medicines.
Pharmacists must complete the MUR training course provided
by the New Zealand College of Pharmacists (NZCP) to be accredited to provide
this service. MURs are not nationally funded and local schemes must be agreed
with DHBs. MURs are reported to be provided in some parts of New
Zealand6 however, to date, there is a paucity
of information on these services
The aims of the present study were to identify where in New
Zealand MURs services are provided by pharmacists, and to collect information on
the processes involved and pharmacists’ perceptions of the service.
MethodA list of all MUR accredited pharmacists to date in New
Zealand was obtained from the NZCP during May 2008. A structured questionnaire
was developed and pilot-tested by five pharmacists, three of whom were community
pharmacists currently undertaking MURs. The draft questionnaire was modified in
the light of their comments. The final version of the questionnaire consisted of
23 questions in four sections comprising of a combination of closed and open
questions.
Questionnaire topics included: participation; location;
pharmacists’ qualifications; source of referrals; interview settings;
criteria for recruitment; duration of interviews; activities involved; follow-up
interviews; actions taken on drug-related problems; referrals and feedback;
documentation; remuneration; and criteria for funding compliance packaging.
Pharmacists’ opinions were sought on the need for
a nationally funded service, documentation, perceived value to patients; and
suggestions to improve the service.The study was approved by the School of
Pharmacy University of Otago Ethics Committee.
An information sheet, consent form, and questionnaire
were mailed to 68 MUR accredited pharmacists during May 2008 along with a
post-paid envelope. To improve the response rate, potential respondents received
three reminders (via electronic mail and/or telephone) during July and August.
Those telephoned were asked whether they were providing MURs and any reasons for
not yet providing a service.
Pharmacists that agreed to participate were requested
to mail the questionnaire back to the investigators along with a blank copy of
any MUR reporting sheet or follow-up record if available. The period of data
collection closed on 5 September 2008.
Information was extracted from completed
questionnaires, entered into a Microsoft Excel spreadsheet and analysed.
ResultsDemographics, participation, and
barriers—Sixty-eight of 71 MUR-accredited pharmacists on the NZCP
list were sent a questionnaire; three pharmacists had no contact details
available. Fifty-four accredited pharmacists responded to the survey giving an
overall response rate of 79%. Among these, 30 pharmacists completed the
questionnaire and were providing the service.
After telephone follow-up, nine initial non-responders were
also confirmed as current MUR providers, three were non-providers, and two were
lost to follow-up (location unknown). At the end of the study, 66 of 68
pharmacists were successfully contacted. So, overall, 39 (57%) of the 68
pharmacists sent a questionnaire were undertaking MURs, 27 (40%) were not.
Five of the 21 DHBs were funding the MUR service by May
2008. The 39 pharmacists providing MURs worked in the following DHBs: Bay of
Plenty (3 pharmacists), Canterbury (12), Capital and Coast (10), Waikato (6),
and Waitemata (8). The study also identified that 33 (3.7%) of 897
pharmacies15 in New Zealand were providing an
MUR service.
Twenty-three of the 27 accredited pharmacists who were not
yet undertaking MURs identified barriers to providing a service: no current
contract agreed with potential funders (7); insufficient time (4); only
“trial” MURs undertaken at present (3); personal circumstances (not
employed at present, been away two months, caring for a sick relative) (3); GPs
and or patients were not interested (2); now working part-time or as a locum
(2); claiming is too complex (1); and achieved accreditation for business
reasons (1).
The 30 respondents currently providing the service that
completed the questionnaire provided the details below.
Duration of service—Of the 30 MUR
pharmacists, over half had undertaken MURs for less than 6 months, five for
7–12 months, three for 13 to 23 months, and six for over 24 months (the
latter were involved in pilot schemes).
Qualifications—Eleven (37%)
pharmacists had undertaken postgraduate study: postgraduate papers (1),
certificates (4), diplomas (4) or a Masters degree (1), or NZCP modules (1).
Referral of patients for MUR—Patients
were referred by general practitioners (reported by 83% of respondents); the MUR
pharmacists (80%), nurses (70%), self-referred (70%), non-MUR pharmacists (67%),
patients’ relatives (57%)—and others (17%) such as patients’
friends, pharmacy staff, or pharmacy clients.
Eligibility criteria of patients for
MUR—MURs were funded for people living in the community or having
one or more chronic disease states and meeting one or more of the specified
conditions—e.g. people taking three or more medicines and/or 12 or more
doses per day (Box 1).
Box 1. Eligibility criteria for
patients
 Setting of MUR interview—Sixteen
pharmacists (53%) reported the interview was undertaken in the patient’s
home or a private area in the pharmacy; seven in a private area of the pharmacy
only; four in the patients home only; two in the GP surgery, and another in a
rest home.
Duration of MUR interview—The MUR
consisted of an initial interview of median 57 minutes (range 30–120
minutes) and follow-up interviews of median 15 minutes (range 5–90
minutes). The pre-interview report writing and preparations were not included in
this period. After the first interview, two or three follow-up interviews took
place.
The typical activities involved in
MUR—After referral of a patient who met the funding criteria, the
pharmacist would collect information on the patient’s medication and
history from the pharmacy record and doctor’s records. Written consent
must be obtained from the GP and the patient prior to undertaking the interview.
Subsequently the pharmacist would arrange a face to face
consultation with the patient. Initial activities (Box 2) included checking the
indication, efficacy, and side effects of each medicine taken; assessing the
signs and symptoms in relation to the patients conditions; checking
patients’ adherence to therapy and medication understanding; assessing the
patients dexterity and medicine management; identifying practical problems
discussing options; and making recommendations.
Box 2. Common activities involved in
MUR
 Follow-up activities included (Box 3) undertaking some
monitoring and assessments appropriate to the patients condition (symptoms,
weight, blood glucose, blood pressure, inhaler technique), monitoring how the
patient is managing any changes and assessing the patient’s knowledge and
understanding of their medicines. Pharmacists would continue to assess whether
the patient met the criteria for compliance (blister) packaging.
Box 3. MUR follow-up assessments
 Contact with other health professionals and
feed-back received—All pharmacists (100%) stated that they
contacted GPs whenever necessary. Others contacted included: the practice nurse
(70%), consultants/specialists (13%), district nurses (13%), community
psychiatric nurses (13%), and others (27%) such as PHO pharmacists or nurse
specialists for diabetes. Eighteen pharmacists (60%) reported receiving
feed-back after contacting other health professionals. Sixteen (53%) of them
received feed-back from GPs, and gave no details of the feed-back (7%). Twelve
pharmacists (40%) said that they had never received feed-back
Documentation—As agreed with the
DHBs, all MUR pharmacists retained consultation records. These were used for
follow-up and audit purposes. Twenty-seven pharmacists (90%) used hard copy
only; one (3%) used electronic copy only; one (3%) used both hard and electronic
copy; and one (3%) did not respond.
Actions taken on drug-related
problems—All respondents would contact the GP regarding a
drug-related problem if considered beyond the scope of the MUR and would
telephone if the problem was urgent. If less urgent they would document the
problem and refer it to the GP or health professional concerned, and follow up
with a phone call later. If appropriate most said they would discuss the problem
with the patient, and some would meet with the GP.
Perceptions and future directions—All
pharmacists perceived the service as highly valuable (93%) or moderately
valuable (7%) to patients. Over half strongly agreed (33%) or agreed (20%) that
MUR should be a nationally funded service, about a quarter disagreed (20%) or
strongly disagreed (7%), and 20% remained neutral.
Over a third strongly disagreed (20%) or disagreed (17%)
that payment was adequate, a similar proportion agreed (30%) or strongly agreed
(7%), and 23% remained neutral. Twenty-seven pharmacists suggested the service
could be improved by funding a computer program for documentation, increasing
the number of MUR interviews and follow-ups per pharmacy per year, promoting the
service more strongly to GPs and patients, and encouraging more feedback from
GPs.
Funding of compliance (blister)
packaging—Compliance (blister) packaging was funded: under
specific criteria (15 pharmacists, 50%); without any criteria set (1 pharmacist,
3%); following the MUR pharmacist’s recommendation (5 pharmacists, 17%);
and 9 pharmacists (30%) stated the packaging was not funded (Box 4).
Box 4. Criteria for funding of compliance
(blister) packaging
 Remuneration—The payment for the
service ranged from $101–$150 (for three interviews) to $181–$200
(for four interviews), plus subsequent documentation.
DiscussionThe present study aimed to identify the New Zealand
locations where the adherence support MUR services are provided by pharmacists,
collect information on the processes involved and pharmacists’ perceptions
of the service.
The study found that MUR services were funded by five DHBs
by May 2008: Bay of Plenty, Canterbury DHB, Capital and Coast, Waikato, and
Waitemata. Thirty-nine accredited pharmacists were performing MURs. This was 59%
of accredited pharmacists with current contact details working in 33 (3.7%) of
New Zealand’s 897 community pharmacies.
Although numbers were small it should be noted that the
service was introduced only a year prior to the survey, and that contracts must
be negotiated with individual DHBs before MUR services can be funded. Indeed,
seven accredited pharmacists were awaiting an agreement with their DHB at the
time of the survey. Anecdotal reports suggest the numbers of pharmacists
involved in MUR are increasing, but statistics are not readily available as the
service is not centrally organised.
At conception, MUR services were intended to be a
collaborative service involving GPs, pharmacists and
patients.14 The study provides some evidence
that this is occurring: GPs and other health professionals are reported to be
involved in the recruitment of patients for MURs; they are provided with
feedback from the reviews, give feedback themselves to pharmacists, and are
contacted appropriately (urgently or in due course) following MURs regarding
drug-related problems. However the study suggests that collaboration might be
improved in some geographical areas as two pharmacists claimed that local GPs
were slow to refer patients. These may be isolated cases but any pharmacist
wishing to set up a MUR service would be wise to discuss this with their local
GPs at an early stage and develop a collaborative approach.
Evidence from other countries supports a collaborative
approach to medication review. The benefits of this have been demonstrated in
Australia16–18 and led to the launch of
the Home Medicines Review (HMR) service in 2001. In this service, GPs select and
refer patients for an HMR by an accredited pharmacist thus HMRs are funded only
where the GP deems them “clinically
necessary”.5 Both GPs and pharmacists are
remunerated for their involvement in the service. Following increased numbers of
MURs in the UK, a government white paper now advocates more GP involvement to
ensure the targeting of reviews to patients in most
need.19
Earlier experiences of collaborative medication review
services in New Zealand, PRS and CPC, may have fostered the development of MUR
services.13 However, unlike annual PRS reviews,
MURs consist of an initial review and two or three follow-ups. This allows
monitoring of the patient’s condition in response to medication changes.
In the present study, some pharmacists thought more follow-ups per year should
be funded so that closer monitoring could take place, however this may not be
feasible until the benefits of MUR have been established.
The present study highlighted a number of barriers to
providing MURs. Most commonly cited were a lack of a local contract, and
insufficient time. The latter is consistent with an earlier study in New
Zealand.20 A national system for claiming
remuneration would remove one perceived barrier, however the present study found
that about a quarter of MUR providers did not want a national contract possibly
preferring local negotiations. Nevertheless the lack of a nationally funded
system may mean that the service will not be accessible to all patients in New
Zealand.
The study found wide eligibility criteria for the funding of
MURs in New Zealand with eligible patients being mainly those living at home
taking many medicines or daily doses and and/or patients with chronic illness.
These were similar to criteria for the HMR scheme in
Australia.5 Nevertheless criteria for MUR may
need to be reviewed if future studies identify patient groups most likely to
benefit.
The study found that all MUR pharmacists perceived the
service as being highly valuable or valuable to patients. However, the present
study did not seek data on patient outcomes as the MUR service is in its
infancy. Future studies are needed on patient outcomes, measuring symptom
control, surrogate markers and so forth, to establish the benefits of MURs.
A common suggestion for improving the service was to
computerise the documentation process. Future research could examine whether
using such a system (a privately developed programme exists in New Zealand)
would improve information flow and lead to any additional benefits to
patients.
There are some limitations to this study. Firstly the study
provides only an outline of the MUR service in New Zealand. A more rigorous
study is needed to assess the benefits of MURs for patients. A randomised
controlled trial or cohort study should be considered in future when the numbers
of pharmacists performing MURs increases. Furthermore, the study did not
quantify the number of MURs undertaken by each pharmacist but simply identified
those performing MURs. At this stage it was considered too early to be
requesting such information, however future studies should attempt to quantify
this.
ConclusionThe present study found that, by May 2008, collaborative
adherence support medication review services (MURs) were provided in five DHBs
in New Zealand: Bay of Plenty, Canterbury, Capital and Coast, Waikato, and
Waitemata. Thirty-nine pharmacists (59% of those accredited to provide the
service) were doing so, from 33 (3.7%) of New Zealand’s community
pharmacies. Patients were referred for MURs by GPs, pharmacists, nurses,
relatives, or by self-referral. MURs took place in patients’ homes,
community pharmacies, and GPs’ surgeries.
As the service framework was launched only a year or so ago,
uptake of the service is low at present. Studies should be undertaken as the
service grows to establish stakeholders’ perceptions of the value of the
service and, most importantly, the impact of MURs on the health outcomes of
patients.
Competing interests: None known.
Author information: Evan Lee, Intern
Pharmacist, Pharmacy@carefirst, New Plymouth; Rhiannon Braund, Lecturer, School
of Pharmacy, University of Otago, Dunedin; June Tordoff, Senior Lecturer, School
of Pharmacy, University of Otago, Dunedin
Acknowledgements: We thank the pharmacists
who made helpful comments on the pilot-tested questionnaire as well as the
pharmacists who responded to the survey.
Correspondence: June Tordoff, Senior
Lecturer in Clinical Pharmacy, School of Pharmacy, University of Otago, PO Box
913, Dunedin, New Zealand. Fax: +64 (0)3 4797034; email: june.tordoff@otago.ac.nz
References:
This article was corrected on 20 November
2009 to reflect the Erratum at http://www.nzmj.com/journal/122-1306/3893
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