THE ROLE OF A CLINICAL PHARMACIST AND POLY-PHARMACY IN
THE PRIMARY CARE CLINIC
Objective - To evaluate the outcomes and acceptance, by both patient and physician,
of a clinical pharmacist (CP) as a member of the health care team in a primary care
setting in Israel.
Research design - Survey
Setting - HMO primary care clinics in Israel
Participants - 50 primary care physicians, recruited on a voluntary basis. Each was
provided with a list of all of his patients that were taking at least five medications.
From this list each physician selected 5-8 patients for CP consultation.
Intervention - Each patient underwent a formal structured interview by the CP. The
CP was allowed to make recommendations concerning the proper use of medications
and lifestyle changes but not make changes to the patient's medications. A summary
report of each interview and the CP's recommendations were sent to the referring
physician and individually discussed. Final treatment decisions were the prerogative
of the treating physician.
Results- During 2004, 414 patient interviews were preformed. 33 patients were
excluded due to death or severe chronic diseases. We report the results from 381
patients. 365 of the patients had at least one or more of the following chronic
conditions: hypertension, diabetes mellitus, ischemic heart disease, asthma and CHF.
56% were over 65, 44% were male and 56 % were female. The number of monthly
prescription medications per patient ranged from 4-18 with a median of 7. More than
50% of the patients took over the counter medications that the referring physician
frequently was unaware of. It was also discovered that many patients took "nutritional
supplements" that they did not consider medications.
The following types of changes were recommended by the CP to the referring
physician: Additional medication (50% of the patients), Discontinue medication
(29%) Alternative medication (26%), Change in dosage (28%), Drug interactions (18
%). In addition the CP made between 1-5 direct recommendations to the patient
concerning the proper use and storage of medications, the use of glucose and blood
pressure home monitoring, the use of nebulizers and inhalers and lifestyle changes.
We had major concerns about the willingness of physicians and patients to accept
recommendations from a CP. We surveyed a random sample of 22 of the participating
physicians to evaluate their response to the process. 100% of the physicians were
satisfied with the process, 81% felt it added to their knowledge and 68 executed the
CP recommendations. 55% also felt that it improved their patient's compliance.
In a random survey of 55 patients, 78% felt that the interview with the CP improved
his knowledge and 89% felt that as a result, they took their medications in a more
orderly fashion.
Conclusions - The results of this study, while recognizing the limitations of a survey,
strongly suggest that there is a need for improved monitoring of medication use in the
primary care setting and that a CP is an appropriate addition to the primary care team.
The role of the primary care physician has changed, and he spends a much greater
portion of his time treating patients with multiple chronic illnesses. These patients
take multiple and complex medication regimens that are difficult both for the patient
and the physician to comply with. This study supports the premise and the need to use
additional support personnel such as a clinical pharmacist to improve compliance. The
next step is to carry out a controlled trial to demonstrate that a CP can result in a
meaningful change in patient outcomes.