No benefit in pharmacist intervention

THE ongoing bid by pharmacists to expand their primary health care role has been struck a blow by US research showing no health benefits from a pharmacy-led medication adherence intervention.

“Unfortunately this adds to the ongoing evidence that these types of pharmacy interventions have no positive health impacts”, Dr Evan Ackermann, chair of the Royal Australian College of General Practitioners’ National Standing Committee for Quality Care, told MJA InSight.

The research, published in JAMA Internal Medicine, randomly assigned 241 acute coronary syndrome (ACS) patients from four medical centres in the US to either the intervention group (n = 122) or usual care (n = 119). (1)

The intervention, which lasted 1 year after hospital discharge, included pharmacist-led medication reconciliation and tailoring; patient education; collaborative care between the pharmacist and the patient’s primary care clinician and/or cardiologist; and voice messaging (educational and medication refill reminder calls).

Although the results showed that 89.3% of those in the intervention group were adherent compared with 73.9% in the usual care group, there was no significant improvement in the proportion of patients who achieved blood pressure and low-density lipoprotein cholesterol level goals.

Dr Ackermann said there was no evidence to support medication interventions in primary care, or for medication reconciliation by a pharmacist at hospital admission or discharge.

“Systematic reviews undertaken by the National Prescribing Service (NPS) and other high-quality reviews consistently fail to find benefit from this type of intervention”, he said. (2), (3)

Dr Ackermann said further research should focus specifically on issues raised by the NPS review.

He called for research priority to be given to medication safety interventions in diseases where medication was an important part of care and where patients were prone to high hospital admission rates (eg, heart failure), the use of drugs associated with a high risk of adverse events, and high-risk settings such as aged care facilities and transfer of care.

He said evidence about the factors contributing to adverse drug events should be used to develop strategies that improved early detection and prevention of adverse drug events.

“I believe this can only occur within the confines of a general practice, using pharmacy funding schemes that do not rely on the sale of medications”, Dr Ackermann said.

An editorial in JAMA Internal Medicine predicted that if the studied intervention were applied to every patient with ACS in the US it “would add $1 billion annually to health care costs”. (4)

“The relatively modest increases in already high rates of medication regimen adherence in the patients studied may not translate into improved outcomes even if maintained for 3 to 5 years or longer”, the author wrote.

Before recommending investment in this strategy, “it would be prudent to know that patient outcomes will actually improve”.

Andrew Matthews, national director for quality assurance and standards at the Pharmacy Guild, said that as medicines experts, pharmacists considered improving medicine adherence as a key role of their profession.

Mr Matthews said the JAMA Internal Medicine research was consistent with other research showing improvement in patient outcomes associated with higher levels of adherence.

“The Guild sees this as further evidence supporting the expansion of pharmacists’ primary health care role”, he said.

1. JAMA Intern Med 2013; Online 18 November
2. National Prescribing Service 2009; Medication safety in the community
3. Br J Clin Pharmacol 2008; 65: 303-316
4. JAMA Intern Med 2013; Online 18 November