Risk minimisation strategies through drug utilisation review

Abstract

The Pharmacy-Of-Your-Choice (POYC) scheme is a national pharmaceutical service that provides free medicines and medical devices to outpatients in Malta through 219 private community pharmacies. The POYC unit prioritises completing pharmacy administrative requirements when approving entitlement to medicines. According to the POYC database, over 14,000 senior adults were prescribed 10 or more drugs to treat a variety of conditions. Clinical services are required for several therapies to provide care continuity across the healthcare system. This study aimed to evaluate and characterise the process of pharmacists’ clinical review at the POYC entitlement unit and to develop a risk minimization strategy through a drug utilisation review. A focus group discussion was organised to understand needs, advantages, barriers, experiences, and prioritisation of a clinical review process within the POYC entitlement unit. Using the information gathered, a Drug Utilisation Review tool feasible for the POYC setting was developed. The tool was validated and applied to a retrospective drug utilisation review of 150 patients (60% male, 40% female) receiving at least 10 entitled medications. The risk of identified drug-related problems for 10 patient cases was assessed by a panel composed of pharmacists and medical practitioners through a matrix table with the "probability" and "consequence" risk ratings on a scale of 1 to 5, indicating very low, low, moderate, high, and very high risk respectively. "Consequence" is the potential outcome of the drug-related problem, while "probability" is an estimate of the chance of an event or an incident happening. Very low-risk drug-related problems require no treatment. Low risk requires self-care, moderate risk is DRPs requiring medical treatment, high risk may require hospital treatment and very high-risk DRPs cause death and permanent disability. From the focus group discussion, patients with multiple conditions and managed with multiple consultants, and with at least 10 medications were identified for prioritisation in the DUR process. From the patient DURs carried out, 84% (n=126) had 10–15 entitled medications with aspirin (67%), amlodipine (61%), omeprazole (58%), metformin (55%), bumetanide (52%), and perindopril (47%) as the most frequently prescribed medications. Hypertension (81%), diabetes mellitus type 2 (58%), and ischaemic heart disease (53%) were the top medical conditions. The main drug-related problems requiring intervention at the prescriber and patient levels identified by the DUR process were potential drug interaction (34%), risk of adverse drug reactions (21%), and potentially unnecessary drug therapy (20%). The most common median risk scores for drug-related problems were 3, 4, and 5, indicating a moderate, high, and very high medication risk, respectively. When used in conjunction with the patient prioritising criteria, the DUR tool results in a systematic pharmacist intervention towards a clinical role during the POYC entitlement appraisal procedure.