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Integrating research, education and practice


Laurence A Goldberg
HPE Editorial Consultant
E:[email protected]

The 5th ESCP Spring Conference was held in Stockholm, Sweden, from 25 to 28 May 2005. More than 650 delegates took part in the plenary sessions and workshops.

Documentation and evaluation
Good communication systems are essential to ensure that critical information in medication profiles is not omitted or altered as patients move between their homes, hospital and care homes, explained Tommy Eriksson (Research Pharmacist, University Hospital of Lund, Sweden). This causes problems at the time of admission, and there is published evidence from several European countries of problems in communication between GPs and hospitals, incomplete medication profiles and errors in the transfer of information. Standardised data collection protocols and preadmission telephone interviews are two ways in which these problems can be avoided.

At the University of Lund, a structured patient medication interview has been developed to assess patients’ adherence, knowledge and attitudes to their medication. The project also checks whether patients have received the correct medication during the first few days in hospital. When used in 47 patients who were capable of taking their own medicines during their hospital stay, it showed that 27 prescription charts contained errors and that 17 patients had insufficient knowledge about their treatment to handle it correctly.

There are also problems when patients are discharged from hospital. Published evidence shows that information about medication is lacking, is not supplied in time, or is incomplete or incorrect. Moreover, the failure to transfer complete, accurate information about medication causes preventable drug-related problems, including preventable unplanned readmissions, said Dr Eriksson.  Discharge planning by pharmacists might offer one solution, he suggested. There are two Cochrane reviews concerned with discharge planning. One review shows that it can make a small reduction in length of stay for elderly patients, along with increased patient satisfaction.(1) The other review concludes that verbal and written information significantly increases knowledge and satisfaction scores.(2) However, few published studies have focused on the pharmacist’s role in the dis­charge process.

A survey of 163 hospitals in the UK showed that a wide variety of methods to communicate information about medicine regimens to GPs were used. There were also wide variations in the provision of discharge counselling, telephone helplines and clear medication records to patients. Few hospitals routinely involved community pharmacies in the discharge process.(3)

Electronic transfer of information appears to be a good solution, although systems are still at an early stage of development and, so far, direct transfer of information is only possible at one site in Sweden. Other approaches that have been reported include postdischarge telephone follow-up by a pharmacist and the provision of discharge summaries to community pharmacies and GPs. In Sweden, the National Board of Health and Welfare has defined the ways in which information should pass between caregivers, using four specific documents:

  • An admission notice.
  • A coordinated care plan.
  • A “ready to leave hospital” note.
  • A discharge message (also given to the patient).

Once again, there is no special emphasis on medication and the details are often missed, Dr Eriksson noted.

The main problem is that if an accurate medication profile is not available at the time of admission, then it is difficult to produce an accurate discharge list. In Dr Eriksson’s hospital, a discharge medication report has been developed that lists the changes made during the hospital stay and the reasons for them. The report is given to the patient, the GP and the community nurse. A prospective study (with historical controls) is now underway to evaluate the impact of the discharge medication reports. Preliminary results (121 intervention patients and 54 controls) show that there has been a reduction in error rates, from 30% to 8%.

The function of a clinical pharmacy service is to produce a correct medication profile and identify drug-related problems. During the hospital stay,  medication changes, reasons and plans should be documented and, at discharge, a medication report should be prepared. Such reports should then be sent or given to the patients, physicians, nurses and pharmacists. If there is no clinical pharmacy service in place, this type of study or a small audit of quality issues could help to catalyse its introduction, suggested Dr Eriksson.

Experience has shown that compliance with statins deteriorates rapidly and can be as low as 60% after two years, according to Marco Oosterveld (Waldeck Apotheek, The Hague, The Netherlands). A randomised trial involving 29 community pharmacies throughout the Netherlands has been set up to evaluate the impact of pharmacist-managed interventions on compliance in a group of first-time statin users. The STIPT (STatin Intervention research ProjecT) trial is a 12-month study that involves statin-naive individuals who have had no other previous lipid-lowering treatments. Community pharmacists are responsible for dispensing supplies of the statin (Crestor) and undertaking follow-up consultations at 3, 6 and 12 months. A detailed protocol is followed and the process is fully computerised. At each meeting, the pharmacist checks compliance, identifies drug-related problems, measures blood lipids and provides education and information about drug treatment. The pharmacists receive a professional fee of €45 for each visit.

Key features in good models of practice for community pharmacy include continuity through system-level improvements, a computerised record-keeping system and a quality assurance scheme. Other factors that contribute to success are reimbursement for the pharmacist and collaboration between patients, physicians and pharmacists. A good way to start proactive pharmaceutical care is to search the pharmacy database for patients who are at risk of suboptimal drug use, added Dr Oosterveld.

A multidisciplinary medicines management project in a London Children’s hospital illustrates one model of hospital clinical pharmacy practice. Sara Arenas-Lopez (Paediatric Pharmacist, Evelina Children’s Hospital, London, UK) works with a pharmacy technician to provide a medicines management service at the hospital (part of Guy’s and St Thomas’ NHS Foundation Trust Hospital). The pharmacist’s duties include attending daily ward rounds, taking drug histories, conducting medication reviews, educating patients and carers, and liaising with the primary care team. The technician is responsible for assessing patients’ own medicines to determine whether they are suitable for reuse, dispensing and labelling of new medicines, and checking patients’ medicines lockers. Part of the programme involves training the patients or carers to administer medicines. During a one-year pilot period, only five parents did not want to administer their children’s medicines.

Medication review
Medication-related problems (MRPs) were detected in 90% of patients interviewed for medication review in a primary healthcare centre in Stockholm, according to Cecilia Lenander (Community Pharmacist, Stockholm, Sweden). Patients aged over 50 years who had a minimum of five regular medicines were eligible for inclusion. They were selected and booked by a nurse. Patients were asked to bring their current medicines to the review. The pharmacist carried out the review and entered in the computerised medical record current medicines, calculated creatinine clearance, identified MRPs and suggested drug changes.

The results from a sample of 80 patients showed that the average number of medicines per patient was 8.7 (range 2–19). Many patients were not taking all of the medicines listed in their records, 50% were taking over-the-counter products unknown to their doctor, and 14% were using herbal remedies. A total of 155 MRPs were found in 80 patients. Lack of knowledge about why they were taking a medicine accounted for 17% of MRPs, and a further 16% had inappropriately discontinued treatment or changed their regimen. Adverse drug events and “poor effect or no effect” made up 15% and 6% of MRPs, respectively. The majority of patients with MRPs were referred to their GPs, but Ms Lenander also provided information about how and why to use medicines. Many patients had read the patient information leaflets and then decided not to take the medicines for fear of side-effects, and had told the pharmacist but not the GP about their decision. Writing in the medical record had not been easy because Swedish pharmacists are not trained to do this, explained Ms Lenander, but overall, the study had been professionally rewarding. Feedback from patients showed that the extra time for questions was particularly valued.

A new study is now planned in which the pharmacist will have consultations with patients before they see the doctor. A control group will follow the usual procedure. The outcome measures will include the number of MRPs, changes in blood pressure, lipids and haemoglobin A(1c), and the number and cost of medicines.

Adherence and response
Enhanced responses to treatment among patients receiving antidepressant medication were found when adherent patients were compared with non­adherent patients. Ann-Charlotte Åkerblad (Department of Neuroscience, Uppsala University Hospital, Sweden) described a study conducted in a primary care setting to measure the effects of a compliance-enhancing educational programme and therapeutic drug monitoring on treatment adherence and response in patients prescribed sertraline by their GPs. Patients from 93 health centres in Sweden participated in the study over a period of six months. The GPs were randomised into three groups: a therapeutic drug monitoring (TDM) group; a compliance- enhancing programme (CP) group; and a control (usual care) group. In the TDM group, plasma concentrations of sertraline and desmethylsertraline were measured at weeks 4 and 12 and fed back to the doctor. In the CP group, patients participated in an educational programme, A helping hand in depression. The programme is not medication-specific but provides educational material and continued support through letters and phone calls. Adherence was measured by questioning, by monitoring of plasma levels of the drug, by adherence to appointments and through a composite index. The response to treatment was assessed using validated depression rating scales. A total of 1,031 patients were included in the study. The results showed that adherence rate varied from 37% to 70% depending on the arm of the study and the method used to measure adherence. Overall, the adherence rate was about 40% and neither of the two interventions made a significant difference. However, there were differences in clinical response rates: 71% of the CP group and 68% of the TDM group were responders, compared with 61% of the control group. Furthermore, there was a strong positive relationship between adherence and therapeutic effect.

Lennart Nathell (Medical Advisor, Pfizer AB, Sweden) explained that A helping hand in depression was an example of a disease management programme that had been developed to improve the quality of care. Disease management attempts to optimise the care continuum in chronic diseases and embraces not only diagnosis and treatment but also primary and secondary disease prevention, he explained. Traditionally, healthcare has been organised in separate disciplines with “component management” rather than disease management, and a strong focus on cost containment rather than health benefits.

The disease management approach builds on the available scientific evidence. It emphasises the prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies. In addition, it evaluates clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving overall health. Open-minded practitioners will find that this approach will strengthen their relationships with their patients.


  1. Johnson A, Sandford J, Tyndall J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database Syst Rev 2003; Issue 4.
  2. Shepperd S, Parkes J, McClaran J, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev 2004; Issue 1.
  3. Sexton J, Ho YJ, Green CF, Caldwell NA. Ensuring seamless care at hospital discharge:a national survey. J Clin Pharm Ther 2000;25:385-93.

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