Exploring the potential impact of integrating pharmacists into general practice in Ireland

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Hurley, Eoin
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University College Cork
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Introduction Globally, due to advances in medicine and public health, populations are living longer. Consequently, the prevalence of multimorbidity and polypharmacy is rising. General practitioners’ (GPs’) workloads are therefore increasing, further compounded by: initiatives to increase the capacity of primary care, the underserved needs of older frail adults in nursing homes, and workforce shortages. In response to growing pressures, pharmacists have been integrated into general practices and affiliated settings in several jurisdictions, most notably in the United Kingdom (UK). Despite evidence showing that pharmacists in general practices improve patient outcomes, they have not been integrated into general practices in many countries. Key gaps in the literature that may be contributing to this include: 1) limited research focusing on GPs’ perceptions of integrating pharmacists into practices, 2) little evaluation of the role of a general practice-based pharmacist in optimising frail older adults’ medications, and 3) economic evidence for the viability of pharmacists in practices outside of the cost savings attributed to deprescribed medications. Therefore, the overarching aims of this thesis were to: i) identify the key factors affecting pharmacist integration into practices through extensive theory-informed engagement with GPs, ii) evaluate the clinical outcomes of a pharmacist-led intervention with frail older adults in general practice-affiliated nursing homes, and iii) to determine the economic viability of the intervention by calculating the costs avoided as a result of the pharmacist-led intervention. Methods Firstly, a qualitative evidence synthesis (QES) was conducted to capture GPs’ views regarding pharmacists working in general practices. Secondly, a qualitative interview study informed by the Theoretical Domains Framework (TDF), was undertaken to explore GPs’ perceptions of working with pharmacists in general practices and identify the behavioural determinants of them doing so. Then, based on the QES and interview study, a mixed-methods survey study was carried out to establish consensus on key issues identified and to determine characteristics of GPs or practices that may be particularly suited to general practice-based pharmacists. Parallel to this work, evaluation of the clinical outcomes from a pharmacist-led intervention in general practices and affiliated nursing homes was conducted; this involved pharmacist-led medication reviews guided by Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) that were carried out on frail older adults. Finally, the economic viability of the pharmacist-led intervention was determined by calculating the cost savings associated with avoided adverse drug events (ADEs) and direct cost savings due to the cost of deprescribed medications. Results Firstly, a conceptual model was developed based on the QES’ findings that described GPs’ views of pharmacists working in general practices, which could be used to develop or optimise pharmacist services in general practice. The QES demonstrated that little research had been conducted that sought GPs’ perceptions of pharmacists working in general practices prior to pharmacist integration. The TDF-informed qualitative interview study that followed identified the predominant behavioural determinants of GPs integrating pharmacists into their practices and found that GPs were broadly optimistic about pharmacists working in GP practices and the potential outcomes of them doing so. However, GPs were concerned about the impact of pharmacists on GPs’ and other practice staffs’ workloads, funding the salary of a general practice pharmacist, and training for pharmacists to work in practices. In the subsequent cross-sectional survey study of GPs (n = 152), the majority (78%) indicated that they would participate in a hypothetical pilot study of having a practice-based pharmacist. Certain roles for pharmacists in practices (e.g. medication reviews) had higher levels of agreement (≥90% agreement) from GPs than other roles (<50% agreement) like independent prescribing. Again, concern was identified amongst GPs concerning the potential impact on workloads, indemnification of pharmacists, and the potential weakening of patient-GP relationships. Evaluation of pharmacist-led application of STOPPFrail to nursing home residents (n = 99), found the most frequently identified potentially inappropriate medications (PIMs) were medications without a clear clinical indication (29.6%) and vitamin D (16.9%). Of the 349 clinically relevant deprescribing recommendations made by the pharmacist, 55% were implemented by GPs. There were significant post-review decreases in the number of prescribed medications, modified medication appropriateness index (MMAI), drug burden index (DBI), and anticholinergic cognitive burden (ACB) which remained significant at six months (p<0.05). There were no significant differences in falls, emergency department visits, non-elective hospitalisations, or quality of life (QoL). Finally, the cost avoidance evaluation of the intervention showed the intervention to be associated with significant cost savings (€24,827 - 251,903). The cost-benefit ratio remained positive in all scenarios examined in sensitivity analyses (1:11.8 - 1:67.6). Conclusion This thesis has made a significant original contribution to knowledge; it has identified key barriers and enablers to integrating pharmacists into practices and shown that there are clear benefits to doing so for patients, GPs, and the wider healthcare system. The embedding of theory into this research has laid the groundwork for future research which seeks to integrate pharmacists into the general practice setting in a theoretically-informed manner, ultimately with the goal of increasing expertise and support within the general practice setting to optimise medications and improve health outcomes for patients.
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Primary care , Pharmacist , General practice , Mixed methods , Deprescribing
Hurley, H. 2024. Exploring the potential impact of integrating pharmacists into general practice in Ireland. PhD Thesis, University College Cork.
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