Author: Lizanne Fernandes

What do you do once you obtain your prescribed medicines? You take them till they finish, then restock. Sometimes, decide that you’re fine and you don’t need to restock. Other times, in lieu of an unpleasant side effect, you may approach a doctor with your concerns.

Well, did you know you could reduce your chances of having adverse reactions to your medications by undergoing a clinical review on a regular basis?

First, let’s get familiar with what a clinical review is.

What is a ‘Clinical Review’?

It is, as the name implies, a review of a patient’s current medications to assess their effectiveness as well as any drug-related problems (DRPs) in order to improve the patient’s quality of life.

What is a DRP, you ask? A drug-related problem (DRP) is any event or condition that has occurred as a result of the use of medicines and has had a negative impact on the patient’s health, such as an adverse reaction, hospitalisation, or even death.

The goal of a clinical review is to identify any DRPs that may have resulted from prescribing or administering errors, and then to propose interventions that the patient agrees on. As a result, it is also known as a ‘Medication Review‘.

Importance of a Clinical Review

People with chronic diseases and the elderly are frequently prescribed multiple drugs at the same time, which is known as ‘polypharmacy.’ If one drug can cause side effects, imagine what multiple drugs at once can do. Furthermore, once a drug has caused an adverse reaction, the patient will require additional medications to treat it.

However, regular clinical reviews can detect and prevent problems like overprescribing or potential interactions between 2 or more drugs.

Clinical reviews can be useful for children and pregnant women as well.

It also has economic benefits because it reduces direct medical expenses by eliminating unnecessary or inappropriate medications, as well as indirect costs associated with treating adverse effects.

Medication reviews are patient-specific, with interventions tailored to the patient’s needs and comfort.

An intervention can look like:

• Deprescribing or cutting down unnecessary medications.
• Changing the dose of the drugs.
• Switching to more a appropriate or tolerable drug alternative.
• Educating patient on the proper use of medicines or medical devices.
• Changing the time at which or the route by which the medicines are taken.

Types of reviews

1. Prescription Review: The pharmacist checks for any under- or overdosage of medications, potential drug interactions, or inappropriate medications, and makes any necessary changes.
2. Adherence or Compliance Review: This is used to determine how compliant the patient is with taking their medicines.
3. Clinical Medication Review: This is a broad assessment of the effectiveness of a patient’s medications on their disease condition as well as any negative effects. This is usually done in collaboration with other healthcare professionals, primarily a physician, a clinical pharmacist, and a nurse.

A clinical review can be performed once every 3-4 months for concise follow-ups focusing on specific concerns, or once a year for a more thorough evaluation.

So where does a pharmacist factor in all of this?

Role of Pharmacists

You’ve probably only met a pharmacist when you went to the pharmacy to get your medications. However, many hospitals employ pharmacists in non-dispensing roles.

These pharmacists are known as ‘Clinical pharmacists’ as they are involved in various clinical activities, including reviewing prescriptions, evaluating drug regimens and providing patient counselling. Many countries have started the Doctor of Pharmacy degree with the aim of training pharmacists to work as part of an interprofessional team to provide patient-centred care.

By virtue of their extensive pharmacological knowledge, these clinical pharmacists make significant contributions to clinical reviews. They can suggest medication-related changes to the physician such as discontinuation of unnecessary & inappropriate medication, changing of dose, changing of drug or drug formulation, or modifications of drug regimens. They may also make recommendations to the nurse regarding administration of medications.

However, not every hospital employs a clinical pharmacist. Clinical medication reviews have traditionally been conducted by physicians, and some countries continue this tradition. Nonetheless, it is gradually becoming apparent that the involvement of various healthcare professionals improves the efficiency of a medication review, and thus the patient’s quality of life.

Now let’s go over what a clinical process should look like.

Clinical Review process

• The first step is to meet with your general physician and discuss your progress and/or concerns regarding your current therapy.
• The physician will then refer you to a clinical pharmacist, who will review your prescription and medical records as well as interview you about your previous and current medications, medical conditions, and any adverse effects you have been experiencing.
• By following an established framework and using their clinical knowledge, the pharmacist will make a decision about the next step to take.
• They will then make their recommendations to the doctor, and a solution will be devised.
• The proposed intervention will then be discussed with you and finalised with your approval.
• Certain recommendations can also be made by the pharmacist to the nurses, involving administering multiple drugs at the same time or changing the route of administration.
• The pharmacist will then ask you to return for future check-ups to assess your progress and to ensure that the recommended changes are being implemented.
• If necessary, new changes would be made.

A review can be conducted via face-to-face meetings or telephone calls. In person reviews were met with better results than other methods.

This process, however, may differ in different parts of the world.

Clinical reviews in different countries

Clinical pharmacist-led medication reviews in long-term care facilities are well established and remunerated in countries such as Australia, Slovenia, and the United States of America. The general practitioner refers the patients to the pharmacist for a medication review. The pharmacist recommends appropriate changes in therapy to the practitioner based on patient interviews, clinical data analysis, and consultation with other healthcare professionals.

A similar procedure is followed in the Netherlands using the STRIP method (Systematic Tool to Reduce Inappropriate Prescribing).

In the United Kingdom, physicians conduct majority of clinical reviews, though pharmacists are increasingly being used in general practises.

In other countries, such as Germany and India, physicians diagnose and prescribe medications. The medications are dispensed by pharmacies and administered by nursing staff.

Pharmacists in collaboration with other healthcare professionals

For maximum optimization of drug therapy and patient safety, it is necessary to involve all relevant professionals. As a result, current reviews include physicians, clinical pharmacists, and nurses. According to studies, a multidisciplinary approach results in a 33-92% reduction in DRPs.

The key to a successful review is clear and effective communication among the various professionals. Communication can take place through direct or indirect contact, such as letters. A pharmacist’s most common contacts are with general practitioners and nurses.

What do the patients think?

The majority of patients who completed a clinical medication review understood that its goal was to evaluate treatment efficacy and detect drug issues. Others regarded the evaluation as part of the repeat prescribing procedure that was required for medication continuation.

During the process, they anticipated their reviewer to ask them about any adverse effects or issues with medication use. They also expected to be given extensive information on their medications, how to use them, and any potential drug interactions. They were expecting changes to be made to their current drug regimen.

Those who were taking medications prescribed by several doctors were pleased to have a combined review of their medications and a better understanding. Patients preferred a familiar reviewer who could give continuity of service and with whom they could discuss their concerns freely.

Some patients felt that having a better knowledge of the review’s aim and good communication prior to the reviews would improve their experience. Medication reviews were seen as unnecessary by some patients, especially those with fewer prescribed medications and those who had no adjustments made to their therapy following a review. These patients also felt comfortable self-managing their medicines and consulting their primary care physician if any difficulties developed.

Telephone calls were preferred by patients because they saved time and energy by not having to meet with the reviewer in person. Others, however, voiced issues regarding the communication, claiming that the information was misconstrued or misheard.  They expressed a major preference for face-to-face communication especially when new medicines were being introduced.

Many patients favoured the role of a pharmacist in a review as they have greater medicinal knowledge than the physicians. A few, however, were sceptical of a pharmacist’s knowledge and expertise.

Barriers

However, there are some barriers that may impede a review’s success.

1. A patient’s lack of understanding of the motive behind a clinical medication review may reduce the value they place on it. As a result, the patient may fail to attend meetings and/or fail to follow instructions.
2. Other issues, aside from prescribing, are sometimes overlooked, such as medication storage or administration, and the use of medical devices.
3. There are time constraints. In such cases, phone calls may appear to be beneficial.
4. A lack of funds.
5. Inadequate clinical data storage. Hard copy data storage may be insufficient and limited.
6. There is no guided framework to assist decision-making.
7. Lack of knowledge about drugs and drug-related issues.
8. Lack of collaboration between the different professionals.

Future Developments

1. Develop a patient information leaflet to encourage patient involvement and participation.
2. Better prior communication and information regarding the objective of drug review and its possible advantages.
3. the need for medication modification, for example, opening capsules or crushing tablets to aid swallowing in dysphagia.
4. Utilization of qualified pharmacists; training programmes for conducting medication reviews are available.
5. Technology can reduce costs by saving time while also improving individual health status. Healthcare professionals can use mobile devices and apps. A computerised decision support system (CDSS) can ensure that a comprehensive review is completed in a timely and cost-effective manner.
6. Using electronic health records, rather than manual records. Individual data can be transferred into the system from clinical information systems or transmitted electronically from medical devices.
7. A step-by-step guided framework will aid in the review process. Automated prompts from software can ensure that every component of a medication review is covered.
8. Lack of standardization in definitions and terminologies can confuse researchers attempting to compare results and confirm the effectiveness. Thus, internationally standardised definitions and terminologies can help in assessing the impact of reviews.

Conclusion

The primary goal of a clinical review or medication review is to identify and minimize drug-related problems, therefore enhancing the patient’s therapy and quality of life. Regular clinical reviews have been demonstrated to benefit patients undergoing long-term treatment by lowering adverse drug responses, hospitalisations, and even mortality. It safeguards patients from obtaining drugs that are unnecessary or incompatible. As a result, it also contributes to the reduction of needless medical costs.

Involving a clinical pharmacist in the medication review process is valuable because their thorough knowledge of pharmaceuticals can aid in recognizing and addressing errors in drug prescribing and administration. Pharmacists working with other healthcare professionals on a patient’s review, such as the general physician and nursing staff, optimises patient care and increases the review’s success.

Patients have generally responded well to a clinical review process, especially when the reason for the review was explained and they were able to freely share their concerns and get clear information. The medication changes also eventually lead to a positive experience with their therapy. Patients who did not comprehend why the review was being undertaken, as well as those who considered it quick and uneventful, did not recognize the value of a review and did not participate in the follow-ups. This can be remedied with adequate patient education and prior discussion.

The pharmacist-led clinical review has yet to be adopted in India, but there is no denying that it would greatly benefit from it.

A competent pharmacist is the backbone of a good medication review. The pharmacist should be trained in critical thinking, adverse effect detection and management, and good communication and collaboration with other healthcare providers. Training programmes for the healthcare team can help improve the efficiency of a review, and thus patient care.