The impact of community-pharmacist-led medication reconciliation process: Pharmacist-patient-centered medication reconciliation.

BACKGROUND AND
PURPOSE: Patients and their healthcare providers' are in need to access a correct and complete list of all patients' active bills for safe and effective clinical care. Currently, Healthcare Information Systems are not providing a proper access to the patients' medications lists. Thus, this study aimed to evaluate the impact of community pharmacist-led medication reconciliation process in community pharmacies in the UAE through applying a pharmacist-patient-centered medication reconciliation (PPCMR).
MATERIALS AND METHODS: This was an interventional study of medication reconciliation process in 25 pharmacies in the UAE during July 1, 2019 till September 1, 2019. The participant pharmacists were surveyed and interviewed to gather more information about the barriers and enablers of the process before and after the implementation of PPCMR.
RESULTS: After the implementation of PPCMR, medication reconciliation service was available in 84% of the pharmacies compared to 40% before the PPCMR (Z = -2.84, P = 0.005). The main workforce barriers to implement this service were reduced to 27% compared to 47% before the PPCMR. The operational barriers for the service were decreased from 56% to 28%. The facilitators in delivering the service in community pharmacies were improved from 29% to 63%. The active collaboration between the pharmacists and physicians was enhanced from 28% to 72% (Z = -3.2, P = 0.001) in the participated pharmacies. There is a statistically significant difference toward the impact of the PPCMR on the whole medication reconciliation service χ2(df = 3) = 200, P < 0.001.
CONCLUSION: Community pharmacists are not always accessible or well placed to provide a medication reconciliation service. The implementation of PPCMR in each community pharmacy will raise the expectations regarding the appropriateness of medication management and use.

INTRODUCTION

Patients and their healthcare providers’ are in need to access a correct list of prescribed and nonprescribed drugs, supplements, and/or herbal formularies when required for safe and effective clinical care.[1234567] Currently, Healthcare Information Systems are not providing a proper access to the patients’ medications lists.[34567]

Medication reconciliation is a well-positioned process that guides the healthcare providers to have a comprehensive view on patients’ medications lists to minimize the medication discrepancies and devastating outcomes.[48] It is a robust process designed to create the most accurate list of medications that the patient can receive by making clinical decisions based on reviewing the current prescribed medications against the medications list that were prescribed for each patient.[14]

The most importantly is to deliver the new medication list to the patients and their healthcare providers’.[4] Even though the pharmacists are the right persons to offer patient-centered medication care that involves reconciling medications, they are not fully involved especially in community pharmacies.[48910] The process has faced a lot of difficulties particularly when the patient transfers between the healthcare settings.[48910]

In the UAE, Department of Health Services has adopted several plans to improve medication management and to expand the roles of community pharmacists in providing responsible drug-monitoring therapy, medication reconciliation, and other pharmaceutical care services.[11] Generally, the pharmacists are well positioned but not fully involved or leading medication reconciliation due to several barriers. Sadek et al.[11] showed that the pharmaceutical care and the expanded roles of community pharmacists are quiet not practically ideal.

In light of this, there was a necessity to determine the physical barriers and enablers of implementing community pharmacist-led medication reconciliation process in community pharmacies in the UAE. This is the first study conducted in the UAE to measure the influence of pharmacist–patient-centered medication reconciliation (PPCMR) in community pharmacies in the UAE and make it more feasible to practice.

MATERIALS AND METHODS

Subjects

This was an interventional study of medication reconciliation process in 25 community pharmacies in the UAE during July 1, 2019 till September 1, 2019. The participant pharmacists were surveyed and interviewed to gather more information about the barriers and enablers of the process before and after the implementation of PPCMR.

PPCMR: the pharmacist designs an individualized patient-centered medication reconciliation in collaboration with the patients and their healthcare providers. Accordingly, each community pharmacy should assign a pharmacist to do the medication reconciliation step before the patient proceeds with his prescription or order.

The data collection was based on the following information: the availability of medication reconciliation service in the pharmacy, the main workforce issues affecting the implementation of the service, the barriers/operational issues and facilitators in delivering the service in the pharmacy, and finally the level of cooperation between physicians and pharmacists to activate the service. This study was approved by the Research Ethics Committee and the pharmacy approvals were collected (AA/2019/32).

Statistical analysis

All data were entered and analyzed using Statistical Package for the Social Sciences (SPSS) software program, version 24.0 (IBM, Armonk, New York). Descriptive statistics were used for measuring the frequencies and percentages. Chi-square and Wilcoxon signed rank tests were used to evaluate the impact of community pharmacist-led medication reconciliation process before and after the implementation of PPCMR. A P value of 0.05 was considered statistically significant, using 95% confidence interval of differences.

RESULTS

The availability of medication reconciliation service in the pharmacy

On the basis of the data collected from the 25 pharmacies, medication reconciliation service was available in 40% (n = 10) of the pharmacies before implementing the PPCMR. However, it was significantly increased up to 84% (n = 21) after implementing the PPCMR (Z = –2.84, P = 0.005).

The main workforce issues affecting the implementation of the medication reconciliation service

The main workforce issues affecting the implementation of the service are shown in Table 1. Before PPCMR, the main workforce issue was the management of elderly patients who take multiple medications and it was noticed in 80% (n = 20) of the pharmacies. However, it was significantly reduced after implementing the PPCMR to 20% (n = 7) (Z = –3.6, p< 0.0001).

Table 1

The percentage of pharmacies that faced main workforce issues before and after implementing the pharmacist–patient-centered medication reconciliation

The main workforce issues	Before (%)	After (%)
Time and repetition	72	28
Staffing	72	64
Organizing the work	68	24
Language	20	20
Old age	80	20
Travelers	28	28
Patients metal status	24	24
Patients’ behavior	32	32
Patients’ ignorance about pharmacist roles	60	16
Pharmacists’ negligence about PPCMR	12	12
Average	47	27

PPCMR = pharmacist–patient-centered medication reconciliation

The time constraints, the repetitive pattern of the process, and lack of staff were the workforce issues for 72% (n = 18) of the pharmacies before the PPCMR. After PPCMR, the time constraints and the repetitive pattern of the process were significantly reduced (28%, n = 7) (Z = –2.8, P = 0.005) but the lack of staff scored in 64% of the pharmacies, n = 16 (Z = –7.1, P = 0.48).

Organizing the work was one of the workforce issues counted for 68% (n = 17) of the pharmacies, which was significantly reduced after implementing the PPCMR (24%, n = 6)(Z = –2.8, P = 0.005).

Considerable number of pharmacists from 15 pharmacies (60%) believed that patients do not realize that pharmacists can help in the management of their mediations as they thought it is the role of their physicians only. After the PPCMR, the percentage was markedly reduced (16%, n = 4) (Z = –2.6, P = 0.008). Although small number of pharmacists from three pharmacies (12%) felt that not all patients need the service, only few of patients require that service before and after the PPCMR.

The language barrier and handling cases of traveler patients as workforce issues were similar before and after the implementation of PPCMR in 20% of the pharmacies, n = 5) and (28%, n = 7), respectively. The patient mental status and patient’s behavior were also similar before and after the PPCMR and reported in 24% (n = 6) and 32% (n = 8) of the participated pharmacies, respectively.

The barriers/operational issues and facilitators in delivering the medication reconciliation service in the pharmacy

The barriers/operational issues in delivering the service in the pharmacy are shown in Table 2. Sixty percent of the pharmacies (n = 15) considered polypharmacy as a barrier to implement the service, while 56% (n = 14) of them faced difficulties in the documentation and 52% (n = 13) had some issues with the pharmacy systems. After the PPCMR, the operational barriers were significantly reduced in the pharmacies (36%, n = 9), (20%, n = 5), and (28%, n = 7), respectively.

Table 2

The percentage of pharmacies faced barriers/operational issues in delivering the service before and after implementing the pharmacist–patient-centered medication reconciliation

The barriers/operational issues	Before (%)	After (%)
Pharmacy system	52	28
Polypharmacy	60	36
Documentation	56	20
Average	56	28

The facilitators in delivering the medication reconciliation service in the pharmacy

Before PPCMR, the facilitators in delivering the service in the pharmacy are shown in Table 3. Before the PPCMR, educating the pharmacy professionals about the importance of the service was facilitator on 56% (n = 14) of the pharmacies. Accessing the patient history was facilitator for 16% (n = 4) only of these pharmacies. The availability of a robust system in place was facilitator for 28% (n = 7) only of these pharmacies.

Table 3

The percentage of pharmacies that used facilitators in delivering the service before and after implementing the pharmacist–patient-centered medication reconciliation

The facilitators	Before (%)	After (%)
Educating the pharmacy professionals about the importance of the service	56	76
Accessing the patient history	16	60
Availability of a robust system in place	28	72
Physicians’ and nurses’ awareness and support	20	68
Patient–pharmacist relationship	20	64
Remunerated pharmacists for this service	32	40
Average	29	63

After the PPCMR, educating the pharmacy professionals about the importance of the service was facilitator on 76% (n = 19) of the pharmacies (Z = –2.2, P = 0.025). Accessing the patient history was facilitator for 60% (n = 15) of these pharmacies (Z = –3.3, P = 0.001). The availability of a robust system in place was facilitator for 72% (n = 18) of them (Z = –3.2, P = 0.001).

Physicians’ and nurses’ awareness and support were considered facilitator on 20% (n = 5) of these pharmacies before PPCMR and reached up 68% (n = 17) after the PPCMR (Z = –3.4, P = 0.001). The patient–pharmacist relationship was recognized as facilitator for 20% (n = 5) of the pharmacies before PPCMR and increased to 64% (n = 16) after the PPCMR (Z = –3.3, P = 0.001). Lastly, the remunerated pharmacists for this service was considered facilitator for 32% (n = 8) and 40% (n = 10) of the pharmacies before and after the PPCMR, respectively (Z = –1.4, P = 0.157).

The level of cooperation between physicians and pharmacists to activate the medication reconciliation service

The cooperation between physicians and pharmacists to activate the service was reported in 28% (n = 7) of the pharmacies. After the PPCMR, it reached up to 72% (n = 18) of the pharmacies (Z = –3.2, P = 0.001).

Figure 1 shows the summary of the comparison of the availability of medication reconciliation service, the workforce issues affecting the implementation of the service, the operational barriers for the service, the facilitators, and the active collaboration between pharmacists and physicians before and after implementation of the PPCMR. There is a statistically significant difference toward the impact of the PPCMR on the whole medication reconciliation service χ2(df = 3) = 200, P < 0.001.

Figure 1

The percentage of pharmacies that have availability of medication reconciliation service, workforce issues affecting the implementation of the service, the operational barriers for the service, the facilitators, and the active collaboration between pharmacists and physicians before and after implementation of the pharmacist–patient-centered medication reconciliation

DISCUSSION

On the basis of this study, the medication reconciliation service has been noticeably improved when the pharmacist led such service. Several studies have proved the significant influence of pharmacists when they integrated in this process.[121314151617] This study showed that the implementation of PPCMR was a successful example of involving the pharmacist directly into medication reconciliation service and improving the medication reconciliation accuracy and efficiency. Multiple organization such as the World Health Organization (WHO) and the American Society of Health-System Pharmacists (ASHP) are seeking pharmacists to do medication reconciliation process as they are the experts in medication management and use.[1819]

In this study, several workface issues have been identified and reported to affect the implementation and activation of the medication reconciliation process such as elderly patients, time constraints, the repetitive pattern of the process, organizing the work, patients’ behavior, and lack of staff. In addition, the polypharmacy, documentation process and the pharmacy systems were the main operational barriers in this study.

These findings were similar to other studies.[202122] Pevnick et al.[23] reported that certain hospitals have limited resources, shortage in pharmacy team and lack of pharmacists’ involvement in the medication reconciliation service. While other studies showed the differences in outcome when other than pharmacist lead the medication reconciliation process.[242526]

Furthermore, Kennelty et al.[21] discussed the barriers that the community pharmacies faced due to the lack of access to patients’ medical records when needed. Another study showed the need for having an electronic-based systems that can be exchanged to facilitate the process.[22]

Interestingly, the implementation of the PPCMR was associated with remarkable resolve of the workforce issues and operational barriers that pharmacists may face when preforming medication reconciliation process.

Notably, to implement the PPCMR, each community pharmacy should assign a pharmacist to do the medication reconciliation step before the patient proceeds with his prescription or order. Accordingly, some pharmacies resist to implement the PPCMR due to the shortage or lack of staff.

In addition, this study highlights the most important factors that can make the implementation and activation of medication reconciliation process easier such as the education, the quick access to patient history profile, the robust system, and the medical team support and patient–pharmacist relationship.

Furthermore, the collaboration between pharmacists and physicians was very low due to the obstacles that pharmacists faced such as the resistance form the physicians toward the pharmacists’ interventions in their conventional treatment plan. However, the implementation of the PPCMR was very helpful for the community pharmacies to activate the medication reconciliation service effectively and to improve the collaboration potentially between the pharmacists and healthcare providers as they start building-up an active connection with medical centers and hospitals.

The study reveals that community pharmacies are not highly accessible or well placed to provide a medication reconciliation service. The implementation of PPCMR in each community pharmacy will raise the expectations regarding the appropriateness of medication management and use.

The current analysis had several strengths; the study is one of the first studies that evaluate the medication reconciliation service in the community pharmacies. In addition, it suggests a new method to improve the medication reconciliation process in community pharmacies.

Acknowledgement

We would like to thank the all the community pharmacy managers and their teams for their participation, cooperation, and valuable contribution in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.