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Senior Lecturer in Pharmacy Practice
*School of Chemical Sciences & Pharmacy
University of East Anglia
**School of Medicine
Health Policy & Practice
†South West Medicines Information & Training
Bristol Royal Infirmary
On the face of it, in England and Wales the question of whether medicines management is pharmacy’s future does not merit asking as, without medicines management, there would be no future for the pharmacist. Unfortunately, the term “medicines management” is specific to England and Wales, and therefore the title may mean very little to a more international audience. This short paper defines “medicines management” and describes its future role for pharmacists. There was a debate on this topic at the British Pharmaceutical Conference in Manchester this year.
Pharmaceutical care is an internationally recognised term that encompasses patient assessment, care plan development and outcome evaluation(1) and is defined as “a practice in which the practitioner takes responsibility for a patient’s drug-related needs, holding him or herself accountable for meeting these needs”.(2) Medicines management is an English and Welsh-adopted term that has been defined by the Department of Medicines Management at Keele University as “seeking to maximise health gain through the optimum use of medicines. It encompasses all aspects of medicines use, from the prescribing of medicines to ways in which medicines are taken or not by patients”.(3) Although pharmaceutical care can be encompassed within the term medicines management, not all medicines management services can be encompassed within the term pharmaceutical care. The two terms are therefore not synonymous. For the purposes of the debate, these distinctions were not made, and the pharmaceutical service chosen for particular consideration was “medication review”, which can be described as an example of either pharmaceutical care or medicines management.
The debate resulted from a recent, highly publicised, large-scale randomised controlled trial carried out in England (the HOMER trial), which demonstrated that post-hospital discharge visits to patient homes to perform medication reviews by community or hospital pharmacists significantly increased the likelihood of those patients being readmitted to hospital.(4) Although a number of questions regarding these findings have been raised,(5,6) adequate response has been provided.(7)
The aim of the debate was, in the context of near-patient medicines management services, to consider the quality of evidence for the provision of such services by pharmacists. The motion was “assuming that pharmacists believe in the theory of evidence-based medicine and that non-evidence based services should not be implemented. Then, with the current paucity of evidence regarding the clinical value of pharmacist-led medicines management services, there is no future in pharmacists providing medicines management services”.
Evidence in support of the motion
Richard Holland (Senior Lecturer in Public Health Medicine at the University of East Anglia), who was the researcher responsible for the HOMER trial, presented the published evidence supporting pharmacist involvement in medicines review services. Although a number of randomised controlled trials performed in the UK have demonstrated reductions in prescribing costs(8) and reductions in drug-related problems,(9,10) none of them has demonstrated any significant improvement in clinical outcomes (ie, mortality, morbidity or quality of life). Table 1 provides a summary of Richard Holland’s brief evaluation of the major randomised controlled trials undertaken in the UK on medication review services provided by pharmacists. For other outcomes (not including mortality, hospital admission or quality of life), the best results from medication review interventions appeared to be seen where the intervention was delivered by a small number of pharmacists working in close collaboration with a general practice, with ready access to a patient’s records. This is, however, only supposition, as not only is there a lack of evidence for positive clinical outcomes from pharmacy services, but there is also little evidence enabling the identification of the best service model.
Finally, Richard Holland, while accepting that drug cost- savings and improvement in the quality of medicines management had been seen from certain medicines review services, questioned whether these were sufficient to justify the service (ie, were these outcomes justifiable once the full cost of the pharmacist service had been taken into account?). Full health-economic evaluations of medication review services should be undertaken rather than simply undertaking cost analyses that include intervention and prescribing costs. Only then could such services be considered to be cost-effective – or not.
Evidence against the motion
Richard Cattell (Director of South West England’s Medicines Information and Training) presented the argument in support of hospital pharmacists continuing their role in near-patient medicines management by discussing in some detail the findings of the relatively recent Audit Commission report A Spoonful of Sugar.(13) With the number of deaths per year in England and Wales from medication errors alone reportedly greater than 1,000 patients,(13) of which a sizeable proportion is believed to be preventable,(14) it would seem intuitive that medicines management services such as medication review should provide identifiable patient benefits. The results from the paper by Bond et al,(15) referred to within A Spoonful of Sugar as providing the greatest evidence for this, are presented in Table 2. It can be seen that, from the four main clinical pharmacy services identified, it is estimated that over 40,000 lives are being saved each year.
In addition, overwhelming evidence has been given by US pharmacists to support pharmacists providing medicines management services.(16–18) In Mr Cattell’s opinion, these two pieces of research were sufficient evidence for pharmacists providing medicines management services and, therefore, the motion should be defeated.
Discussion and vote
Members of the audience, which consisted of pharmacists and pharmacy students, surprisingly addressed their questions to Mr Cattell by saying that the research presented by Bond et al was benefit by association, so it was not direct evidence of the benefit of pharmacy services. In a similar vein, due to the large differences that exist between UK and US healthcare systems, evidence of intervention success in one country would not necessarily translate to the other.
After considering both sides of the argument and discussion, the motion was changed to “The lack of good-quality evidence demonstrating the patient benefits of pharmacist- led medicines management services is not the same as evidence demonstrating negative patient benefits. Pharmacists should work towards better quality research regarding pharmacist-led medicines management services.” That motion was passed.