Medicines may improve health, but can also cause damage. Research has shown that medicines can result in hospitalization and that in almost half of these hospitalizations, one or more prescription errors play a role.
Some of these hospitalizations can be prevented by performing a medicine assessment. Pharmacotherapy is optimized by involving the patient in pharmacotherapy and by having the pharmacist and the general practitioner perform a medicine assessment together with the patient.
It proves difficult to implement this intervention in daily practice and the intended effect of pharmacotherapy does not seem to be achieved.
In the POINT study, we created a new position: the pharmacist-pharmacotherapist in primary care practice. This pharmacist works on optimal pharmacotherapy geared to the individual patient and improves at-risk medication-related processes. This pharmacist's only responsibility is pharmacotherapeutic care; they have no duties in the pharmacy.
By having this pharmacist-pharmacotherapist be part of the primary care practice, we expect that the physician's trust in the pharmacist increases, that availability and accessibility of the pharmacist will increase and that the pharmacist's knowledge and expertise are sufficient to perform these care tasks.
The different research groups measure and compare the following results at the beginning and end of the project period: Hospital Admissions Related to Medication (HARMs), medicine use and changes in medication (number of medicines, type of medicines, prescribed strength and dosage, changes in dosage, drug interactions, refill compliance, stopping/switching medication, missing co-medication, costs of medication), prescription indicators, patient satisfaction and costs based on invoiced healthcare.
The results are measured at population level in the general practices linked to the Network of General Practitioners of the Julius Center, Zorggroep Almere and the Registratie Netwerk Universitaire Huisartspraktijken Leiden en Omstreken. No measurements are performed at patient level.
The analyses are expected to be completed by the summer of 2019, after which they will be published.
A pharmacist-pharmacotherapist works together with the patient's general practitioner and the general pharmacist in an integrated primary care setting and is co-responsible for the effective and safe pharmacotherapeutic care of the individual patient, and responsible for adequate medication records of the patient. The pharmacist-pharmacotherapist is coordinator of pharmacotherapeutic management, for which they use the patient's pharmacotherapeutic treatment plan, which sets out the treatment objectives, tasks and responsibilities.
The pharmacist-pharmacotherapist has a proactive way of working for the benefit of their patients. The pharmacist-pharmacotherapist has great analytical ability, enabling them to conduct effective risk analyses that result in treatment proposals for the individual patient and in improvement of drug safety for the population in the practice. In exercising their profession, the pharmacist-pharmacotherapist relates pharmacotherapeutic expertise with complaints, symptoms and expected outcomes of the individual patient and their wishes, capabilities and ideas.
The pharmacist-pharmacotherapist is responsible for pharmacotherapeutic management of the patient in order to:
- optimize the effectiveness and safety of the pharmacotherapy of the individual patient;
- optimize the quality of medicinal policy in the integrated primary care setting;
- increase drug safety in primary care.
In this project, the pharmacist-pharmacotherapist works as an independent professional in general practice, together with the general practitioners, general practice-based nurse specialists, practice nurses and other healthcare professionals. The pharmacist-pharmacotherapist has a consulting room for medical consultations. The pharmacist-pharmacotherapist also makes house calls to patients who are unable to come to the practice.
Areas of responsibility
The pharmacist-pharmacotherapist effects this responsibility in the following areas:
1. pharmacotherapeutic patient care for individual patients, for which they see patients during their consulting hours or visit them at home, providing advice and consulting general practitioners about pharmacotherapeutic issues;
2. providing pharmacotherapy training to staff in the general practice;
3. pharmacotherapeutic quality policy in the general practice and in the transfer to the general pharmacy.
Pharmacist-pharmacotherapist vs public pharmacy
A public pharmacy provides pharmacotherapeutic care related to the provision of medicines. They provide information with the first and second issue, give inhalation instructions for new medicines, and check new or changed medicines for interactions, contraindications, double medication, dosage and indications of decreased therapy loyalty. The public pharmacist is responsible for smooth completion of these processes and safeguarding drug safety. The public pharmacy can identify pharmacotherapeutic issues and the public pharmacist refers patients to the pharmacist-pharmacotherapist.
The pharmacist-pharmacotherapist refers to the public pharmacy for provision of medication of the annual prescription and for information and checks of ingestion of medication, such as inhalation medication.
The pharmacist-pharmacotherapist and the public pharmacist make arrangements on medication monitoring and issue of related improvement plans or protocols. The public pharmacist has access to the formulary and can hold the pharmacist-pharmacotherapist or prescribing physician accountable if this is deviated from. The public pharmacist can identify frequent or serious medication errors and discuss these with the pharmacotherapist.
The study is focused on the effectiveness and feasibility of the (non-dispensing) pharmacist-pharmacotherapist in general practice by comparing the results of three different groups. Every group has a different setting in which the pharmacist works and/or has been trained:
- The (non-dispensing) pharmacist-pharmacotherapist in general practice;
- The public pharmacist in the pharmacy who has attended intensive training in the assessment of medication;
- The public pharmacist in the pharmacy (regular care).
The pharmacist-pharmacotherapist in the first study group coordinates pharmacotherapeutic management in primary care and is responsible for optimizing the long-term medication of individual patients. The pharmacist-pharmacotherapist does this within the general practice, in the following manners:
- pharmacotherapeutic patient care for individual patients during the pharmacist's consulting hour;
- advice and training about pharmacotherapy to staff in the general practice;
- taking responsibility for writing protocols and formulary in the general practice and keeping these up to date.
- The pharmacist-pharmacotherapist will be responsible for pharmacotherapeutic care of complex patients: patients who take multiple medicines and have multiple disorders and are at a high risk of undertreatment and adverse effects of pharmacotherapy. The public pharmacist provided dispensing-related care, is manager of operational processes and identifies, signals and refers patients to the pharmacist-pharmacotherapist.
The feasibility of healthcare innovation in the first study group is studied by means of a qualitative investigation of how a pharmacist-pharmacotherapist can be implemented in every general practice at practice, regional and national level.
The total duration of the research project is 36 months. The intervention by the pharmacist-pharmacotherapist in general practice will take place over a period of 12 months, with an onboarding period of 3 months. The intervention will take place in 10 different general practices in the period from March 2014 to mid-2015.
The results in terms of hospital admissions related to medication, medication-related problems and the stakeholder study and educational program have since been published in the thesis by Ankie Hazen.Also see 'publications' in the right-hand menu) .
The final analyses are expected to be completed by the summer of 2019.
UMC Utrecht, Julius Center
Prof. Dr N.J (Niek) de Wit, Supervisor
Dr D.L.M. (Dorien) Zwart, Project leader
Drs. A.C.M. (Ankie) Hazen, Pharmacist-researcher
Drs. V. (Vivianne) Sloeserwij, General practitioner and researcher
Dr J.M. (Judith) Poldervaart, Postgrad
Prof. Dr M.L. Bouvy, Supervisor
University of Groningen
Prof. Dr J.J. de Gier, Supervisor
Erasmus University Rotterdam
Dr A.A. de Bont, Co-supervisor
Thesis by Ankie Hazen: non-dispensing clinical pharmacists in general practice: training, implementation and clinical effects.
The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: A systematic review.
Hazen ACM, de Bont AA, Boelman L, Zwart DLM, de Gier JJ, de Wit NJ, Bouvy ML. Res Social Adm Pharm. 2017 Apr 22. pii: S1551-7411(16)30579-4.
Controversy and consensus on a clinical pharmacist in primary care in the Netherlands. Hazen AC, Wal AW, Sloeserwij VM, Zwart DL, Gier JJ, Wit NJ, Leendertse AJ, Bouvy ML, Bont AA. Int J Clin Pharm. 2016 Oct;38(5):1250-60.
Design of the POINT study: Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in a primary care Team (POINT). Hazen AC, Sloeserwij VM, Zwart DL, de Bont AA, Bouvy ML, de Gier JJ, de Wit NJ, Leendertse AJ. BMC Fam Pract. 2015 Jul 2;16:76.
Apotheker ondersteunt huisarts in de praktijk: het beste van 2 werelden. Farma Magazine June 2015
Flinke medicatiereductie, grote verbetering kwaliteit van leven. Pharmaceutisch Weekblad, May 8, 2015
Interventies leiden tot halvering medicatielijst. Pharmaceutisch Weekblad, Febr. 6, 2015